integrative mind body skills for regulating the autonomic ... · 2345 crystal drive! crystal park...

2345 Crystal Drive ! Crystal Park 4, Suite 120 ! Arlington, Virginia 22202 ! 877-291-32631335 East West Highway ! 9th Floor, Suite 640 ! Silver Spring, Maryland 20910 ! 301-295-3257

www.dcoe.health.mil!!!!!Outreach!Center:!866"966"1020!

!Mind"Body!Skills!for!Regulating!the!Autonomic!Nervous!System!

!Defense!Centers!of!Excellence!for!!Psychological!Health!and!Traumatic!Brain!Injury!!!

!June!2011!Version!2!!!!

2345 Crystal Drive ! Crystal Park 4, Suite 120 ! Arlington, Virginia 22202 ! 877-291-32631335 East West Highway ! 9th Floor, Suite 640 ! Silver Spring, Maryland 20910 ! 301-295-3257

www.dcoe.health.mil!!!!!Outreach!Center:!866"966"1020!

!Authors:!!Monique!Moore,!PhD!!David!Brown,!PsyD!!Nisha!Money,!MD,!MPH,!ABIHM!!Mark!Bates,!PhD!!!Acknowledgement:!!Ziggy!Majumdar,!Ph.D.!Thomas!A.!Van!Dillen,!Ph.D.!Kathleen!Sun!!Robert!R.!Ireland,!MD,!DMin,!MA!John!Killen,!PhD!Elizabeth!Stanley,!PhD!Laurie!Leitch,!PhD!Elaine!Miller"Karas,!LCSW!Gregory!L.!Fricchione,!MD!!Emma!Seppala,!PhD!Richard!Davidson,!PhD!Jon!Kabat"Zinn,!PhD!David!Berceli,!PhD!Jennifer!Alford,!PhD!James!Gordon,!MD!Belleruth!Naparstek,!LISW,!BCD!Jennifer!L!Strauss,!PhD!Matt!Fritts,!MPH!Charles!Hoge,!,!M.D.,!COL!(ret)!!Authors’!Positions!at!DCoE:!!Monique!Moore,!PhD,!Program!Evaluation!Development!Manager!(Resilience!&!Prevention!Directorate)!!David!G.!Brown,!PsyD,!Recovery!Support!Care,!Program!Manager,!(Resilience!&!Prevention!Directorate)!!Nisha!N.!Money,!MD,!MPH,!ABIHM,!Contractor!(Resilience!&!Prevention!Directorate)!!Mark!Bates,!PhD,!Director!of!Resilience!and!Prevention!Directorate!!

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!TABLE!OF!CONTENTS![I!edited!some!section!headings,!so!you’ll!need!to!line!them!up!with!this]!

Executive!Summary....................................................................................................................................... 1!Background ......................................................................................................................................... 1!Literature!Review................................................................................................................................ 2!Conclusion........................................................................................................................................... 4!

Introduction!and!Background ....................................................................................................................... 5!

Practices!!for!Regulating!the!Autonomic!Nervous!System!(ANS) ................................................................. 7!Emotions,!Arousal!and!the!ANS .......................................................................................................... 7!Breath!Techniques!for!Regulating!the!ANS.......................................................................................11!Posture!and!Tension"Modulation!Techniques!for!ANS!Regulation ..................................................17!Mindfulness,!Meditation!and!Guided!Imagery .................................................................................24!Mind"Body!Programs ........................................................................................................................33!Biofeedback!......................................................................................................................................37!

Summary!and!Conclusion ...........................................................................................................................38!

Bibliography ................................................................................................................................................42!Appendix!A:!Glossary! .................................................................................................................................48!Appendix!B:!Additional!Resources!!! ...........................................................................................................50!Appendix!C:!Interviewee!List!!.....................................................................................................................52!Appendix!D:!Portable!ANS!Measurement!Tools ........................................................................................ .53!!!!

TABLES!!Table!1.!Comparative!Summary!of!Breath!Practices………………………………………………………………………………15!!Table!2.!Comparative!Summary!of!Posture!and!Tension!Modulation!Practices………………………………………22!!Table!3.!Comparative!Summary!of!Mindfulness,!Meditation!and!Guided!Imagery!Practices………………….31!!Table!4.!Comparative!Summary!of!Mind"Body!Practices………………………………………………………………………..39!!

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Mind"Body!Skills!for!Regulating!the!Autonomic!Nervous!System!

Executive!Summary!

BACKGROUND!

Since!the!beginning!of!Operation!Enduring!Freedom!and!Operation!Iraqi!Freedom,!more!than!two!million!U.S.!troops!have!been!deployed.!The!operational!tempo!associated!with!these!conflicts,!in!conjunction!with!extended!and!multiple!deployments,!exposure!to!nontraditional!combat!(e.g.,!urban!settings!and!use!of!improvised!explosive!devices),!and!shortened!dwell!time!between!deployments,!has!placed!unprecedented!stress!on!service!members!as!well!as!their!families.1"3!With!the!complex,!varied!and!prolonged!operational!demands!of!these!missions,!it!is!crucial!that!the!military!continue!to!develop!and!refine!strategies!for!promoting!and!sustaining!the!health!and!resilience!of!service!members.!A!systems!perspective!on!health!and!resilience!seeks!to!establish!good!functioning!and!balance!across!all!body!systems!(e.g.,!homeostasis!and!harmony)!through!integration!of!beneficial!health!and!mind"body!practices.!!!!!!!!!!!This!review!focuses!on!promising!integrative!practices!(also!referred!to!as!mind"body!practices)!for!regulating!stress!via!the!autonomic!nervous!system!(the!ANS).!The!practices!reviewed!are!focused!more!specifically!on!integrative!mind"body!techniques!designed!to!help!regulate!and!manage!stress,!emotions!and!arousal!(i.e.,!strategies!for!lowering!anxiety!when!it!is!too!high!or!for!increasing!arousal!when!it!is!too!low).!Routine!pharmaceutical!and!psychological!interventions!are!often!a!last!resort!for!helping!people!manage!stress!and!their!emotions.!Consideration!of!the!spectrum!of!mind"body!approaches!to!help!mediate!and!manage!stress!before!it!becomes!too!intense!to!self"manage!provides!a!preventative!approach!to!strengthening!resilience!and!prevention!of!psychological!health!difficulties.!!!Rather!than!providing!a!comprehensive!review!of!all!integrative!mind"body!techniques!that!may!prove!promising,!the!review!focuses!on!a!sample!of!13!techniques!and!limits!its!focus!to!strategies!and!programs!that!have!been!used!in!military!contexts!and!that!can!be!incorporated!into!existing!resilience!promoting!programs!or!trainings,!or!that!can!be!learned!and!taught!by!line!leaders,!peers,!and!support!agencies!in!a!non"clinical!context.!Each!of!the!techniques!featured!were!selected!based!on!their!popularity!and!interest!within!military!and!veterans!hospital!settings,!along!with!their!potential!for!peer"to"peer!based!practice!and!dissemination.!In!addition,!founders!or!trainers!of!practices!featured!in!the!present!report!were!directly!contacted!for!input!regarding!the!research!and!theoretical!basis!of!their!techniques,!as!well!as!to!ensure!accuracy!of!information!presented.!!The!advantages!and!disadvantages!of!the!13!integrative!techniques!reviewed!in!this!paper!were!compared!on!the!basis!of!their!training!features,!ease!of!use!(practice!features!and!practice!requirements),!settings!for!use,!trainability!and!level!of!evidence!(or!demonstrated!effectiveness!in!clinical!research!trials).!Techniques!reviewed!were!broadly!categorized!as!

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falling!within!three!domains!of!integrative!practice:!(1)!breath!exercises;!(2)!!body"based!tension!modulation!exercises,!and!(3)!mindfulness,!meditation!and!guided!imagery!techniques.!The!review!promotes!an!integrative!approach,!recognizing!that!no!technique!provides!an!absolute!or!assured!benefit,!that!some!work!well!in!combination!with!other!integrative!and!conventional!techniques,!and!that!some!will!be!effective!in!some!individuals!and!not!others.!!!It!is!worth!noting!that!while!integrative!techniques!are!highlighted!in!the!present!report!are!primarily!focused!on!as!stress!management!and!prevention"focused!interventions,!integrative!mind"body!practices!have!also!been!gaining!increased!attention!in!the!military!as!potential!augmentative!treatment!strategies!in!a!number!of!conditions,!including!post"traumatic!stress!disorder!(PTSD)!and!chronic!pain.4!5!!!LITERATURE!REVIEW!

Breath!

Research!suggests!that!breathing!can!be!affected!by!experiences!and!circumstances.!When!faced!with!a!distressing!moment,!the!body!can!become!over"activated!and!breathing!can!become!more!rapid!and!shallow.!Fortunately,!breathing!is!controllable.!Breathing!exercises!have!been!used!to!help!manage!emotions!and!regulate!stress,!as!well!as!increase!energy!and!maintain!optimal!arousal!needed!for!greater!focus!and!performance.!Because!breathing!exercises!can!be!quickly!learned!and!provide!immediate!feelings!of!relief,!they!can!be!easily!incorporated!into!existing!trainings!or!treatments.!!For!example,!stress!reduction!breath!techniques!can!be!easily!incorporated!into!pre"deployment!as!well!as!mission!trainings!and!breathing!exercises!are!a!standard!component!of!most!manualized!treatments!for!PTSD!and!other!anxiety!disorders.5!Further!research!is!needed!to!determine!possible!longer!term!benefits!of!breath!practice!as!well!as!to!examine!which!components!of!breath!exercise!might!allow!for!the!most!efficient!stress!and!anxiety!relief.!Breath!techniques!that!are!comparatively!reviewed!in!this!report!include!paced!breath,!diaphragmatic!breathing/!Breathe2Relax!(a!computerized!breath!practice!device),!and!Sudarshan!Kriya!Yoga.!

!Body"Based!Tension!Modulation!Practices!

Body"based!practices!have!become!increasingly!popular!in!both!military!and!civilian!settings.!Stress!and!anxiety!are!reflected!physically!in!many!ways.!Techniques!such!as!yoga!and!tension!manipulation!have!been!studied!for!their!effects!on!stress!and!anxiety.!Research!suggests!that!these!techniques!can!have!positive!effects!on!stress!management!and!anxiety!disorders,!such!as!post"traumatic!stress!(PTS).!These!techniques!are!considered!to!work!to!reverse!stress!postures!and!regulate stress!hormones.!It!is!also!believed!that!posture!and!tension"release!techniques!specifically!balance!nervous!system!functions.!Further!research!is!needed!to!gain!a!better!understanding!of!the!ways!in!which!specific!tension!exercises!and!yoga!postures!might!differentially!affect!mood!and!arousal.!Body"

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based!techniques!reviewed!in!the!present!report!include!yoga!postures!(also!known!as!“asanas”),!Trauma/Tension!Release!Exercises!(TRE)!and!the!Trauma!Resiliency!Model!(TRM).

!Mental!Focus!Practices!(Mindfulness,!Meditation,!and!Guided!Imagery)!

Mindfulness!practice!is!regarded!as!a!potential!means!for!greater!relaxation,!attention!control,!working!memory!functioning!and!lessening!of!distressing!thoughts.!Several!meta"analytic!reviews!indicate!that!routine!mindfulness!practice!can!reduce!symptoms!of!depression!and!anxiety.!Additionally,!recent!research!indicates!that!mindfulness!may!be!helpful!to!promote!feelings!of!well"being!and!for!increasing!attention!control!and!cognitive!flexibility.!There!is!a!need!for!more!rigorous!randomized!clinical!trials!in!the!area!of!mindfulness!to!prove!beneficial!findings!conclusive.!In!particular,!there!is!a!need!to!compare!the!potentially!effective!components!of!popular!mindfulness!techniques!to!one!another!as!well!as!to!compare!mindfulness!to!other!more!traditional!approaches!to!therapy!and!wellness!enhancement!(e.g.,!exercise,!therapy!and!psychopharmacology).!Mindfulness!techniques!comparatively!reviewed!in!this!report!include!Mindfulness!Based!Stress!Reduction!(MBSR),!and!Mindfulness!Mind"Fitness!Training!(MMFT).!Additionally,!although!many!forms!of!meditation!and!prayer!targeting!relaxation!exist,!for!this!paper,!only!Yoga!Nidra!(iRest)!was!reviewed.!!Related!to!mental!practices,!guided!imagery!is!regarded!as!potentially!effective!for!managing!stress,!anxiety,!and!depression!as!well!as!for!pain!management!and!performance!enhancement.!While!studies!investigating!the!use!of!guided!imagery!across!these!areas!appear!promising,!on!the!whole,!many!studies!examined!combined!imagery!techniques!with!other!interventions!such!as!hypnosis,!cognitive"behavioral!therapy!and!relaxation!techniques,!which!make!it!difficult!to!definitively!conclude!that!guided!imagery!was!an!active!component!in!improvement.!More!research!is!needed!to!investigate!types!of!imagery!techniques!that!may!be!effective!and!to!assess!the!relative!effectiveness!of!specific!techniques!across!applications.!!Mind"Body!Programs!

A!confluence!of!techniques!for!regulating!the!ANS!may!prove!to!be!more!effective!than!one!integrative!mind"body!skill!in!isolation.!Several!are!offered!in!a!non"clinical!context!for!military!populations,!as!delivered!from!the!Center!for!Mind!Body!Medicine!and!the!Benson"Henry!Institute!for!Mind!Body!Medicine!at!Massachusetts!General!Hospital.!Integrative!mind"body!programs!offer!the!user!the!opportunity!to!access!a!host!of!approaches!typically!within!one!location!making!scheduling!and!access!easier.!Although!the!two!programs!reviewed!share!a!common!theme!and!some!similarities!in!approach,!a!critical!review!reveals!distinct!differences!in!application.!!!!

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Biofeedback!

Because!the!ANS!regulates!a!number!of!biological!processes,!measuring!biological!functions!regulated!by!the!ANS!can!provide!an!indicator!of!arousal!levels!and!feedback!that!might!be!used!to!regulate!as!well!as!monitor!arousal.!Portable!biofeedback!tools!are!available!to!measure!and!monitor!ANS!functions,!in!particular!heart!rate!variability!(HRV).!HRV!reflects!the!healthy!alternating!balance!of!sympathetic!and!parasympathetic!effects!as!increased!HRV!is!associated!with!improved!cognitive!performance.!Individuals!can!be!trained!to!increase!the!degree!of!HRV!and!biofeedback!devices!could!be!important!tools!for!training!individuals!to!regulate!various!aspects!of!ANS!functioning.!A!table!of!portable!ANS!measures!and!user"friendly!biofeedback!tools!can!be!found!in!Appendix!D!of!the!present!report.!!CONCLUSION!

The!results!of!this!review!suggest!that!integrative!practices!designed!to!regulate!the!ANS!and!improve!mood,!stress!regulation!and!arousal!are!promising.!However,!in!order!for!these!and!other!related!practices!to!achieve!greater!recognition!and!use!in!the!mainstream!military!health!community,!there!is!a!need!to!compare!the!relative!effectiveness!of!techniques!(independently!or!as!augmentative!strategies),!to!each!other,!as!well!as!to!other!more!mainstream!stress!and!energy!management!practices,!such!as!exercise,!counseling!or!psychopharmacology.!Finally,!there!is!a!need!for!more!studies!that!examine!promising!integrative!practices!within!the!context!of!“real!world”!military!operational!settings.!!DISCLAIMER!

All!practices,!programs,!and!products!reviewed!in!this!report!are!presented!for!critical!review!and!are!not!officially!endorsed!by!the!Defense!Centers!of!Excellence!for!Psychological!Health!and!Traumatic!Brain!Injury!(DCoE).!One!goal!of!this!paper!is!to!provide!an!example!of!some!of!the!latest!resources!and!supporting!evidence!on!integrative!modalities!Consequently,!we!plan!to!provide!revised!versions!of!this!paper!in!the!future!with!updated!information.!!The!practices!reviewed!in!this!report!have!not!necessarily!undergone!formalized!medical!evaluation!procedures.!Before!practicing! the! techniques!highlighted,! it! is!advised! that! service!members!check!first!with! their!primary!health! care!provider! to!ensure! there!are!no! contraindications!or!potential!safety! concerns.! It! is! recommended! that! techniques! be! taught! by! trained! practitioners! who! are!certified!by!a! recognized!national!organization!and!who!abide!by! the!organization's! standards.! ! If!these! techniques!are!utilized! in!medical! treatment! settings!or! administered! by!medical!providers,!they! should! be! administered! as! augmentative! strategies! along! with! accepted! evidence"based!treatments!that!meet!current!standards!of!care.!!

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Introduction!and!Background!

Maintaining!the!health!of!the!force!continues!to!be!a!high!priority!for!the!Defense!Department!(DoD).!In!the!Chairman!of!the!Joint!Chiefs!of!Staff!(CJCS)!Guidance!for!2011,!Admiral!Mike!Mullen!reaffirmed!that!the!health!of!the!force!remains!one!of!the!top!priorities!that!direct!the!military’s!course.!Mullen!stressed!the!need!for!a!“holistic”!approach!to!caring!for!service!members!and!their!families.6!!In!response!to!Mullen’s!request!for!holistic!approaches!to!health!care,!a!priority!at!the!Defense!Centers!of!Excellence!for!Psychological!Health!and!Traumatic!Brain!Injury!(DCoE)!is!to!identify!and!fully!leverage!a!comprehensive!range!of!health!practices!that!accord!with!Mullen’s!Health"Of"The"Force!strategic!vision!for!Total!Force!Fitness.!The!DoD"wide!integration!of!the!Total!Fitness!Model!is!evolving!and!DoD!is!working!to!identify!best!practices!that!contribute!to!its!success!and!to!share!and!make!visible!identified!best!practices!across!the!services.!As!part!of!the!mission!to!promote!holistic!and!comprehensive!approaches!to!health,!this!paper!puts!forward!a!number!of!integrative!mind"body!health!practices!for!review.!Integrative!practices!presented!focus!on!interactions!between!body!and!mind!to!enhance!control!over!emotions,!stress!management!and!arousal.!The!review!focuses!on!certain!integrative!practices!that!have!received!particular!attention!recently!!and!for!which!there!has!been!speculation!that!they!offer!advantages!in!helping!individuals!achieve!control!over!stress,!arousal!and!emotions!than!some!more!traditional!talk"based!or!behavioral!treatments.7!!!!Based!on!a!systematic!review!of!the!various!terms!used!in!the!field!of!complementary!and!alternative!medicine,!this!paper!uses!the!term!“integrative”!to!describe!the!combination!of!different!health!and!wellness!approaches!that!traverse!the!domains!of!mind"body,!complementary,!integrated!and!non"conventional!medicine!modalities!and!practices.!!The!term!integrative!is!consistent!with!Mullen’s!vision!of!holistic!health,!as!integrative!medicine!recognizes!that!health!is!more!than!the!absence!of!disease!and!that!a!multi"disciplinary!approach!to!health!promotion!often!provides!the!maximum!therapeutic!benefit.8!!In!the!context!of!this!review,!the!term!“integrative!mind"body!practices”!is!used!more!narrowly!to!describe!the!combination!of!different!health!and!wellness!approaches!to!ANS!regulation!from!the!larger!domains!of!complementary!and!alternative!medicine.!!This!review!focuses!specifically!on!a!sample!of!integrative!mind"body!programs!and!techniques!that!individuals!themselves!can!practice!that!may!prove!useful!for!regulating!stress!and!emotions!in!order!to!better!meet!mission!demands.!While!there!has!been!much!research!conducted!and!literature!published!assessing!and!reviewing!conventional!clinically"based!therapies!for!counseling,!less!attention!has!been!given!to!integrative!mind"body!practices,!despite!their!growing!use!within!both!military!and!civilian!settings.!This!review!emphasizes!mind"body!exercises!that!have!been!used!in!military!settings,!have!garnered!interest!among!the!services!and!DoD!because!of!their!potential!for!complementing!and!

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enhancing!performance!of!military!operations,!and/pr!show!promise!for!effectiveness,!portability!and/or!ease!of!use.!Interventions!were!also!selected!for!review!because!they!can!be!taught!by!non"licensed!professionals!and!practiced!by!any!individual.!!A!caveat!is!that!many!of!the!techniques!outlined!in!this!report!require!specialized!training!certification!before!techniques!may!be!safely!trained!to!others.!Integrative!mind"body!techniques!outlined!in!the!present!report!are!offered!for!consideration!due!to!their!dissemination!possibilities!and!are!presented!as!possible!tools!for!use!by!line!leaders,!wellness!support!facilities!or!for!incorporation!into!existing!or!emerging!resilience!training!or!programs.!!!Finally,!it!is!anticipated!that!some!of!these!techniques!could!be!given!special!consideration!for!incorporation!into!expanding!peer"to"peer,!or!buddy"aid!approaches!to!promoting!health!and!resilience.!Due!in!part!to!a!current!health!care!provider!shortage!and!fears!of!stigma!that!can!thwart!help"seeking!behavior,!peer"to"peer!programs!are!emerging!across!DoD!as!a!promising!avenue!for!preventative!health!as!well!as!for!optimizing!health!and!resilience.9!The!ability!of!non"licensed!health!professionals!or!laypersons!to!be!trained!in!practices!that!can!be!used!peer"to"peer!in!combat!environments!is!also!being!increasingly!explored!as!a!way!forward!for!primary!prevention.9!Because!all!programs!surveyed!in!this!report!can!be!taught!to!non"health!care!professionals,!they!may!be!incorporated!into!existing!or!emerging!peer"based!training!programs.!!

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Practices!for!Regulating!the!Autonomic!Nervous!System!(ANS)!

EMOTIONS,!AROUSAL!AND!THE!ANS!

The!autonomic!nervous!system!(ANS)!is!the!branch!of!the!nervous!system!that!functions!independent!of!conscious!awareness.10!!It!involves!the!unconscious!regulation!of!organs!and!system!functions!that!maintain!basic!operations!within!the!body—for!example,!heart!rate,!digestion,!respiration!rate,!salivation,!blood!pressure,!perspiration!and!diameter!of!the!pupils.!The!ANS!is!a!functional!system!within!the!central!and!peripheral!nervous!system!that!manages!all!of!the!body's!internal!functions.11,12!!It!is!the!automatic!nature!of!the!ANS!that!enables!the!regulation!of!many!systems!without!interfering!with!everything!else!the!brain!is!responsible!for!on!a!daily!basis!involving!conscious!thoughts!and!emotions.13!!The!autonomic!nervous!system!has!two!components:!sympathetic!(SNS)!and!parasympathetic!(PNS).!The!SNS!prepares!the!body!to!fight,!flee,!or!freeze!in!stressful!situations!(depending!on!the!circumstances),!while!the!PNS!prepares!the!body!to!rest!and!digest!in!relaxing!situations.14!!These!sub"branches!both!supply!nerves!to!various!central!and!peripheral!nervous!system!regions,!the!endocrine!system,!and!visceral!organs.12!The!SNS!becomes!dominant!in!states!of!stress!and!fear.!Signs!of!SNS!activation!include!increased!heart!rate!and!respiration,!cold!and!pale!skin,!dilated!pupils!and!raised!blood!pressure.!In!contrast,!the!PNS!becomes!dominant!in!states!of!rest!and!relaxation.!Signs!of!PNS!dominance!include!decreased!heart!rate!and!respiration,!warm!and!flushed!skin,!normally!reactive!pupils!and!lowered!blood!pressure.!Because!PNS!and!SNS!states!are!associated!with!distinct!body!activities,!a!variety!of!biofeedback!instruments,!such!as!those!that!measure!heart!rate,!body!temperature,!blood!flow,!pupil!dilation!and!breathing!are!often!used!to!indicate!the!body’s!ANS!arousal!state.!!!Stress!and!stress!vulnerability!can!be!broadly!defined!as!either!the!absence!of!adequate!balance!between!the!ANS!and!the!PNS!during!resting!states!or!the!improper!predominance!of!one!over!the!other!in!particular!situations.!For!example,!it!would!be!dysfunctional!to!have!PNS!predominance!during!times!requiring!high!energy!and!arousal,!such!as!when!under!threat!or!attack.!Equally,!it!would!be!dysfunctional!to!have!SNS!predominance!during!times!of!relaxation,!such!as!when!readying!for!sleep.!!Research!in!affective!neuroscience!(the!study!of!correlates!between!the!brain!and!emotion)!has!identified!central!nervous!system!(CNS)!regions!involved!in!emotion.!This!research!suggests!that!emotions!involve!a!mix!of!cortical!(e.g.,!frontal,!temporal!and!parietal)!and!subcortical/limbic!(e.g.,!basal!ganglia,!thalamus,!amygdala!and!hippocampus)!regions!of!the!brain.12,15!Evolving!alongside!this!research,!emerging!neurophysiological!research!has!sought!to!identify!the!ANS!correlates!in!emotion.!!!Mounting!research!over!the!past!three!decades!suggests!a!relationship!between!emotions!and!changes!in!the!ANS.16"24!There!is!some!evidence!that!different!emotions!may!be!

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distinguished!based!on!a!complex!pattern!of!sympathetic!and!parasympathetic!activation.25,26!However,!this!literature!is!evolving!and!there!are!relatively!few!studies!that!have!simultaneously!examined!brain!activity!and!ANS!responses!while!experiencing!emotions,24,27!making!it!difficult!to!determine!specific!pathways!and!conclusions!about!ways!in!which!the!brain,!the!ANS!and!emotional!experiences!relate!to!one!another.!Nonetheless,!research!exploring!connections!between!the!ANS!and!emotions!via!associated!networks!in!the!CNS!continues!to!expand,24,28!and!researchers!continue!to!look!for!some!of!the!specific!ways!that!mood!and!emotions!may!be!connected!simultaneously!to!the!brain!(i.e.,!the!mind)!and!to!the!ANS!(i.e.,!the!body),!in!addition!to!how!interventions!designed!to!directly!manipulate!the!ANS!and!body!may!impact!moods!and!cognitive!abilities.!!Porges’!Polyvagal!Theory!provides!an!organizing!principle!by!which!we!might!better!understand!how!some!individuals,!especially!those!who!experience!trauma!or!high!levels!of!stress,!experience!a!dysfunctional!imbalance!between!PNS!and!SNS!responses.!The!Polyvagal!Theory!suggests!that!there!is!a!modulating!or!regulating!role!played!by!the!vagus,!or!10th!cranial!nerve.!The!vagus,!which!connects!to!various!brain!regions!and!interacts!with!the!SNS!and!PNS,!serves!as!a!brake!or!modulator!between!the!systems!and!across!the!brain.!Thus,!it!influences!behavioral!mobilization!in!response!to!social!interactions!and!interoceptive!visceral!awareness.29,30!!Interoception!refers!to!sensitivity!to!stimuli!originating!inside!the!body,!a!type!of!bodily!perception!that!contributes!to!how!someone!“feels.”!Thus,!it!is!tied!to!mind!and!body!and!integral!to!one’s!sense!of!“being”!or!well"being!and!emotions.29,30!Conditions!of!extreme!stress!can!break!down!this!highly!sensitive!means!for!stabilizing!the!human!organism.!The!theory!suggest!that!when!the!vagus!fails!to!modulate,!the!brain!relies!on!phylogenetically!older!parts!of!the!brain!(fight!or!flight)!to!regulate!response.!The!person!loses!the!ability!to!distinguish!friend!from!foe,!or!adjust!behavior!based!on!social!interaction!and!the!environment.!The!loss!of!modulated!interoception,!that!is,!the!ability!to!correctly!respond!to!“gut!feelings”!or!correctly!interpret!social!cues,!is!diminished!and!the!person!is!no!longer!able!to!manage!visceral!or!emotional!feedback!being!received.!!!In!addition!to!the!ANS’s!role!in!the!affective!experience,!arousal!may!be!the!link!between!basic!emotions!and!linkages!to!CNS!and!ANS!connections.24!This!is!to!say!that!emotions!are!an!integration!of!multiple!cortical!and!sub"cortical!regions!and!several!sympathetic!and!parasympathetic!response!systems.15,24,31!Furthermore,!neural!processes!associated!with!arousal!are!complex.!They!are!thought!to!be!a!physiological!and!psychological!state!involving!cortical!and!subcortical/limbic!regions!of!the!brain,!including!the!ANS.32!As!such,!maintaining!optimal!levels!of!arousal!would!ideally!include!harnessing!a!combination!of!cortical!interventions!(e.g.,!techniques!designed!to!stimulate!positive!thoughts!and!enhance!emotional!motivation)!as!well!as!!body"focused,!interventions!designed!to!keep!the!ANS!and!body!alert!and!aroused,!but!regulated!enough!not!to!become!overly!aroused!or!distractable.28!!

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Given!the!role!that!the!autonomic!and!related!sub"cortical!brain!functions!have!in!motivation,!performance!and!emotional!states,!some!people!have!criticized!traditional!Western!psychotherapy!approaches!to!mood!and!arousal!regulation!for!paying!insufficient!attention!to!the!often!involuntary!and!unconscious!aspects!of!human!emotion!and!motivation.7!Psychodynamic!approaches!do!address!unconscious!motivation,!and!cognitive"behavioral!approaches!(e.g.,!imaginal/narrative!exposure,!in"vivo!exposure,!or!cognitive!restructuring!and!cognitive!behavioral!therapy),!and!so!address!bodily!awareness.!That!said,!critics!point!out!that!while!many!conventional!Western!approaches!to!managing!emotions!and!stress!tend!to!be!heavily!reliant!on!verbal!interaction!only,!many!mainstream!practices!in!Eastern!cultures!root!their!healing!and!emotion!management!traditions!in!body"based!techniques!(e.g.,!yoga,!meditation,!breath!techniques!and!acupuncture).!These!techniques!either!bring!awareness!to!the!body!or!directly!manipulate!the!body!to!bring!about!desirable!mood!and!energy!states.7!Several!of!these!body"based!interventions!have!been!speculated!to!modulate!the!ANS,!to!bring!about!optimal!energy,!emotional!or!arousal.7,16,33!!!Although!many!traditional!Eastern!practices!have!become!popular!in!the!West,!critics!argue!that!the!emphasis!of!Western!psychology!on!verbal!interaction!have!kept!Eastern!approaches!on!the!fringe!of!mainstream!psychology!and!psychological!teaching.7!Perhaps,!in!part,!due!to!cultural!biases,!Eastern!practices!have!remained!marginalized,!despite!empirical!findings!that!several!traditionally!Eastern"based!interventions!(including!breathing,!yoga!and!mindfulness!practices)!are!promising!for!helping!regulate!stress,!emotions!and!a!wide!variety!of!mental!health!conditions.33"38!!It!is!postulated!that!these!practices!have!the!capacity!to!affect!various!physiological!parameters!associated!with!the!ANS,!primarily!through!reduction!in!arousal!as!measured!by!galvanic!skin!response,!heart!rate!and!heart!rate!variability,!blood!pressure,!metabolic!activity!and!neuroendocrine!and!hormonal!activity.33"38!!An!especially!promising!avenue!for!the!use!of!integrative!skills!techniques!may!be!in!the!area!of!PTSD!recovery.7!An!important!component!of!overcoming!trauma!is!learning!to!regulate!one’s!physiological!arousal!in!response!to!reminders!and!to!fully!engage!in!one’s!present!experience,!as!practiced!in!exposure"based!interventions.!Currently,!cognitive!behavioral!interventions!and!psychopharmacological!approaches!for!regulating!anxiety!and!emotions!have!predominated,!but!various!mind"body!approaches!have!shown!promise!to!positively!affect!a!variety!of!disorders,!including!anxiety,!depression,!headaches,!chronic!pain!and!insomnia.!The!clinical!literature!on!the!treatment!of!PTSD!and!other!stress!and!anxiety!disorders!consistently!suggests!that!being!able!to!regulate!affective!arousal!is!critical!to!coping!with!the!traumatizing!experience.!!The!new!VA"DoD!Clinical!Practice!Guidelines!for!PTSD!acknowledges!the!potential!role!of!many!integrative!modalities!as!augmentation!strategies!in!the!treatment!of!symptoms!related!to!PTSD,!particularly!symptoms!related!to!hyperarousal.5!!In!addition,!it!suggests!that!these!modalities!may!foster!a!patient"centered!approach!to!care!that!leads!to!greater!willingness!to!engage!in!and!continue!with!care.5!!

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!This!review!surveys!promising!integrated!practices!for!regulating!the!ANS.!The!evidence!for!each!practice,!along!with!outline!of!next!steps!in!determining!their!validity!and!utility!is!presented.!!The!review!encompasses!a!survey!of!breath,!meditation!and!body"based!modulation!techniques,!as!well!as!exercises!that!have!been!used!in!military!settings.!!!!

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BREATH!TECHNIQUES!FOR!REGULATING!THE!ANS!

Breath!practice!is!central!to!the!ancient!healing!practices!of!yoga,!qigong,!Ayurveda!and!other!meditation!disciplines.!While!most!functions!of!the!ANS!are!involuntary!(e.g.,!blood!pressure,!sweating,!pupil!dilation!and!digestion),!respiration!can!be!directly!manipulated.!As!such,!breath!is!the!primary!!function!of!the!ANS!over!which!humans!can!exert!direct!control.16,39!!!Although!the!research!linking!specific!breath!techniques!to!ANS!arousal!levels!is!slow!to!emerge,!it!has!been!hypothesized!that!breath!practices!can!affect!the!ANS!in!either!direction,!meaning!toward!increased!arousal!or!relaxation,!depending!on!the!breath!technique!used!and!pace!of!breathing!practiced.16!Unlike!many!ANS!functions,!breathing!is!under!both!voluntary!and!involuntary!control!via!complex!feedback!mechanisms!involving!autonomic!visceral!networks,!the!limbic!system!(the!seat!of!emotions)!and!associated!cortical!regions!of!the!brain!including!the!pre"frontal!cortex!(the!seat!of!planning!and!executive!control)!and!the!neuroendocrine!system40!(which!regulates!health!and!immunity).!Research!has!increasingly!demonstrated!that!conscious!control!of!breath!and!routine!breath!practice!may!be!particularly!effective!at!facilitating!feelings!of!calm!and!focus!during!times!of!excessive!anxiety!and!stress40"42!(SNS!hyper"arousal).!!!!A!review!of!some!of!the!particular!breath!practices!that!appear!to!hold!promise!for!helping!regulate!arousal,!emotion,!stress!and!anxiety!are!surveyed!below.!!!Paced!Breathing!Paced!respiration!is!defined!as!inhaling!and!exhaling!at!a!predetermined!rate.!Typically,!participants!are!asked!to!coordinate!their!breathing!rate!with!counting,!lights,!sounds,!or!metronome"like!devices.!!It!has!been!theorized!that!increased!states!of!arousal!and!attention!can!be!brought!about!using!a!faster!pace!of!breath43!and!that!feelings!of!calmness!can!be!induced!through!practicing!a!slower!pace!of!breath.16,44!!As!Clark!and!Hirschman!elucidate,!“It!is!thought!that!respiratory!activity!exerts!a!significant!regulatory!effect!on!cardiac!activity!and!that!because!high!heart!rate!and!high!respiration!is!often!linked!to!anxiety,!by!slowing!down!respiration!(which!slows!heart!rate),!one!can!lower!anxiety,!or,!in!reverse,!by!speeding!up!respiration!pace,!one!can!accelerate!heart!rate!and,!possibly,!increase!arousal.”44!!!Though!there!is!some!indication!that!fast"paced!breathing!may!help!increase!arousal!and!attention,16,43!there!are!few!studies!to!validate!these!findings.!In!contrast,!a!growing!number!of!studies!support!the!conclusion!that!slow"paced!deep!breathing!can!be!used!to!effectively!manage!feelings!of!anxiety34,35,45"48!(to!include!PTSD!symptoms)!as!well!as!stress.48"50!The!theory!behind!these!findings!is!that!when!we!are!relaxed!and!calm!we!naturally!breathe!slowly!and!deeply.!Thus,!practicing!slowed!breathing!can!bring!the!ANS!!back!toward!parasympathetic!dominance!to!achieve!more!balanced!levels!of!arousal.16,51!!

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In!support!of!the!theory!that!breathing!can!be!used!to!restore!ANS!balance!during!times!of!high!anxiety,!several!studies!have!used!physiological!measures!to!indicate!linkages!between!slow"paced!breathing!and!the!ANS.44,48"50,52,53!!Researchers!found!that!when!respiration!was!paced!below!participant!baseline!rates,!the!ANS!was!more!balanced!in!individuals!prone!to!anxiety!(SNS!hyper"arousal)!as!evidenced!by!less!electro"dermal!responsiveness!at!multiple!time!points!over!an!extended!period.52!Further!studies!suggest!that!regular!practice!of!slow!breathing!can!increase!resting!heart!rate!variability,48"50!!!which!has!been!found!to!be!associated!with!greater!feelings!of!calmness!and!parasympathetic!activity.!Mounting!research!indicates!that!slow!breathing!holds!potential!to!help!regulate!anxiety!as!well!as!facilitate!improvements!in!cognitive!functioning,!especially!during!times!of!anxiety!and!excessive!stress.48"50,54!

!While!few!studies!examine!how!much!breathing!practice!is!needed!to!achieve!results,!one!study!indicates!that!beneficial!effects!of!slow!breathing!can!be!experienced!in!as!little!as!20!minutes!spaced!over!two!days,!even!in!populations!with!high,!chronic!anxiety.!In!a!study!by!Clark!and!Hirschman,44!36!alcohol"dependent!inpatients!scoring!high!in!trait!anxiety!were!randomly!assigned!to!practice!20!minutes!of!slow!breathing!divided!into!two!10"minute!practice!sessions.!As!expected,!following!breathing!practice,!paced!subjects!evidenced!significantly!greater!reductions!in!self"rated!tension,!state!anxiety!and!skin!conductance!levels!(indicated!less!hyper"arousal!and!SNS!activity)!compared!to!the!control!subjects.!While!study!conclusions!are!limited!due!to!small!sample!size,!they!suggest!that!relatively!small!amounts!of!slow!breathing!practice!may!be!highly!effective!at!lowering!anxiety!and!arousal,!even!in!severely!anxious!populations.!Further!studies!are!needed!to!validate!how!much!breathing!practice!is!needed!to!achieve!optimal!results!or!more!lasting!SNS!control.!!In!addition!to!its!stipulated!ability!to!manipulate!autonomic!arousal!and!help!regulate!excessive!anxiety,!some!researchers!have!speculated!that!paced!breathing!can!be!used!to!manipulate!mood!states.16!!In!support!of!this!theory,!one!researcher!found!that!by!having!participants!practice!breathing!at!different!rates!(and!at!various!levels!of!depth!and!pace!regularity),!breathing!pace!could!be!found!to!account!for!up!to!40!percent!of!the!variance!in!the!experience!of!the!emotions!of!anger,!fear,!joy!and!sadness,!with!faster"paced!breathing!contributing!to!more!agitated!emotions.16!Though!these!findings!are!to!be!considered!preliminary!due!to!poor!study!design!and!small!sample!size,!the!suggestion!that!emotional!experiences!can!be!induced!by!changing!breathing!pace!and!patterns!is!intriguing!and!!points!to!a!potentially!fruitful!area!for!future!research.!!Sudarshan!Kriya!Yoga!(SKY)/Warrior!Breath!A!yoga!breathing!technique!called!Sudharshan!Kriya!Yoga!(SKY)!involves!four!types!of!controlled!cyclical!breathing!patterns.34,55!In!SKY!yoga,!participants!are!instructed!to!close!their!eyes!and!engage!in!several!breathing!techniques!through!the!nostrils!for!60!minutes!while!focusing!on!the!chant!“So!Hum,”!as!well!as!on!their!breath!and!the!sensations!it!produces!in!the!body.!During!the!practice,!three!different!breathing!cycles!are!used:!slow!(8–14!cycles!per!minute),!medium!(30!per!minute),!and!rapid!(150–180!per!minute),!ending!with!a!set!of!slow!cycles!and!a!5"minute!

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period!of!backrest.!The!practice!of!SKY!is!preceded!by!eight!to!10!cycles!of!ujjaya!breathing!(slow"paced!deep!breaths!with!resistant!constriction!at!the!base!of!throat),!and!eight!to!10!cycles!of!bhastrika!breathing!(fast"paced!forceful!breaths!through!the!nose).!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Studies!indicate!that!regular!practice!of!SKY!can!increase!mental!focus,!heighten!alertness56!and!may!be!particularly!effective!for!the!treatment!of!depression!and!depressive!symptoms.57,58!There!is!also!some!indication!that!SKY!may!be!effective!for!the!treatment!of!PTSD,35!though!fewer!studies!are!available!to!demonstrate!SKY’s!effectiveness!for!the!treatment!of!anxiety!related!disorders.!SKY!proponents!argue!that!SKY!has!a!greater!number!of!health!benefits!and!works!faster!to!reduce!anxiety!than!other!breathing!techniques!due!to!the!intensity!of!the!breathing!exercises!practiced.34!!In!terms!of!mechanisms!of!action,!several!studies!indicate!that,!as!is!the!case!with!slowed!breathing!exercises,!SKY!(in!conjunction!with!ujjaya!and!bhastrika!breath!exercises)!may!increase!parasympathetic!(vagal)!tone!as!demonstrated!by!increased!base!heart!rate!variability,!slow!base!heart!rate!and!decrease!anxiety!symptoms!with!practice.34,55!!As!a!caveat!to!promising!findings,!it!might!be!argued!that!the!slowed!breathing!component!within!SKY!practice!may!alone!account!for!the!finding!that!SKY!lowers!anxiety.!It!is!also!possible!that!the!fast"paced!breathing!component!of!SKY!may!serve!to!arouse,!rather!than!calm!the!ANS,!and!thus!accounts!for!reports!of!increased!alertness!and!decreased!feelings!of!depression!in!SKY!practitioners.!!More!studies!that!investigate!connections!between!SKY!and!autonomic!indicators!are!needed!to!determine!whether!SKY!practice!reliably!lowers!anxiety,!as!well!as!to!further!elucidate!the!biological!and!neurological!processes!involved!in!SKY!practice.!Research!further!examining!the!autonomic!and!biological!correlates!of!SKY!practice!in!individuals!with!PTSD!is!underway!at!the!Laboratory!for!Affective!Neuroscience!at!the!University!of!Wisconsin,!Davidson!under!the!direction!of!Drs.!Emma!Seppala!and!Richard!Davidson!(personal!communication,!July!23,!2010).!!In!terms!of!training!features,!SKY!is!typically!taught!through!the!Art!of!Living!Foundation,!which!holds!a!patent!on!the!technique.!Although!studies!have!not!yet!been!conducted!to!determine!how!much!practice!is!needed!for!maximum!benefit,!training!instructors!recommend!30!minutes!per!day!of!SKY!practice!for!40!days.!The!SKY!technique!can!be!learned!through!introductory!courses!taught!by!certified!instructors!over!2"3!days.!A!version!of!the!course!called!“Warrior!Breath”!recently!debuted!in!several!veterans!hospitals!across!the!country!for!the!treatment!of!PTSD.!The!veteran!version!of!the!course!is!taught!over!6"7!days!in!3"4!hour!sessions!per!day!(J.!Osborne,!Personal!Communication,!July!14,!2010).!!The!Warrior!Breath!version!of!the!course!focuses!on!slow"paced!ujjaya!breaths!and!incorporates!shorter!periods!of!SKY!practice!than!is!typically!taught!in!introductory!courses.!This!modified!program!has!not!yet!been!empirically!tested.!!As!a!word!of!caution,!while!SKY!has!been!practiced!by!many!individuals,!the!practice!has!not!been!fully!evaluated!or!medically!approved.!Critics!of!SKY!argue!that!rapid!breathing!cycles!involved!in!the!SKY!routine!may!induce!respiratory!alkalosis,!an!experience!akin!to!

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hyperventilation,!caused!by!an!imbalance!of!carbon!dioxide!in!the!body.59!Further!research!is!needed!to!determine!the!validity!of!these!criticisms!as!well!as!to!determine!if!SKY!is!appropriate!for!all!individuals.!If!critics!are!correct,!the!SKY!technique!may!be!not!be!recommended!for!individuals!with!panic!disorder!as!well!as!for!individuals!with!cardiac!conditions!or!seizure!disorders.59!!!Diaphragmatic!Breathing!The!diaphragmatic!breathing!technique!consists!of!slow,!controlled!respirations!to!aid!in!reducing!sympathetic!arousal60!!and!decreasing!muscle!tension!throughout!the!body.!A!common!pattern!of!dysfunctional!breathing!in!individuals!with!increased!stress!or!anxiety!is!the!tendency!to!breathe!in!the!chest!area.60!Chest!breathing!is!one!of!the!chief!characteristics!of!hyper"arousal!of!the!sympathetic!nervous!system,!which,!during!high!stress!or!anxiety,!becomes!a!part!of!the!physiological!anxiety!response.60!Diaphragmatic!breathing!may!contribute!to!reversing!this!anxiety!response!by!forcing!a!pattern!of!diaphragmatic!breathing!which!is!typically!associated!with!parasympathetic!activity!and!feelings!of!relaxation!and!calm.60,61!!While!diaphragmatic!breathing!can!be!self"taught!or!learned!through!instructional!CDs!or!videos,!computer"based!applications!are!being!developed!to!speed!up!the!learning!process!and!to!help!individuals!pay!closer!attention!to!their!breath!and!its!physiological!effects.!A!free!smart!phone!applications,!“Breathe2Relax”!is!a!portable!rehearsal!tools!for!diaphragmatic!breathing.!!The!portable!program!can!be!used!as!a!standalone!stress!reducer!that!can!be!downloaded!directly!onto!the!iPhone!as!well!as!other!smart!phones.!!Although!diaphragmatic!breathing!is!a!simple!technique!that!can!be!practiced!anywhere!without!the!aid!of!technology,!advantages!to!smart!phone!breath!rehearsal!tools,!such!as!the!Breathe2Relax,!is!that!they!provide!platforms!for!tracking!breath!practice!so!that!users!can!better!monitor!stress!triggers!as!well!as!monitor!progress.!In!addition,!these!techniques!serve!as!a!portable!support!tool!that!is!readily!on!hand.!In!addition,!the!Tactical!Breathing!Trainer!allows!users!to!chose!among!a!variety!of!types!of!breath!techniques.!!!In!terms!of!features,!the!Breathe2Relax!application!is!divided!into!four!major!multimedia!program!areas.!Overall,!these!content!areas!include:!(1)!learning!about!the!fight!or!flight!stress!response!via!an!interactive!video!demonstration;!(2)!learning!about!the!benefits!of!controlled!diaphragmatic!breathing!and!how!to!breathe!with!the!diaphragm;!(3)!tracking!progress!(users!can!rate!and!track!their!pre/post!stress!ratings!across!practice!sessions!on!a!graphical!dashboard);!and!(4)!log!notes!and!track!stress!triggers!"!users!can!tag!personalized!notes!to!breathing!practices!to!help!identify!triggers!that!contribute!to!feelings!of!stress!or!anxiety.!!!Overall,!diaphragmatic!breathing!takes!just!minutes!to!learn.!As!with!slow"paced!breathing,!there!is!some!indication!that!continued!practice!may!strengthen!parasympathetic!tone!and!provide!quick!relief!during!times!of!anxiety!and!hyper"arousal.34!Technologies!such!as!Breathe2Relax!and!biofeedback!devices!that!teach!individuals!to!pay!closer!attention!to!their!breathing!and!to!more!regularly!monitor!connections!between!breathing,!stress!and!

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mood!may!further!boost!the!effectiveness!of!diaphragmatic!breathing!techniques.!Studies!involving!the!use!of!technology!to!accelerate!or!encourage!the!positive!benefits!of!breathing!practice!are!presented!as!a!potentially!rich!area!for!further!investigation!and!research.!!Breathing!Techniques:!Conclusions!and!Future!Areas!of!Research!Research!tracing!the!effects!of!breathing!manipulation!techniques!and!breathing!paces!on!the!ANS!has!been!slow!to!emerge.!Many!research!studies!cited!in!the!above!review!have!used!small!samples!and!varying!methodologies.!Furthermore,!few!studies!have!been!conducted!to!compare!breathing!techniques!or!to!determine!how!much!practice!is!needed!to!achieve!optimal!benefit.!Nonetheless,!there!is!mounting!evidence!that!breathing!practice,!particularly!slow"paced!breathing!and!diaphragmatic!breathing,!can!strengthen!parasympathetic!tone!and!help!regulate!anxiety!and!arousal.!Innovative!technologies,!such!Breathe2Relax!may!help!maximize!these!effects,!as!well!as!be!used!by!clinicians!and!researchers!to!help!track!more!long"term!benefits!of!breathing!practice.!Table!1!provides!a!summary!of!breathing!techniques!reviewed!and!their!different!features!and!mechanisms!of!action.!!Table!1.!Comparative!Summary!of!Breath!Practices!!

Program!or!Model!

Training!features! Proposed!Mechanisms!and!Goals!

Evidence!Rating!

Practice!Features! Trainer!Requirements!

Practice!Settings!

Slow"Paced!Breathing!

Group,!individual!or!self"instruction!with!multi"media!aid,!10"30!mins.!daily.!

Reverse!fast"paced!breathing!associated!with!anxiety.!Practice!increases!parasympathetic!tone!and!reduces!anxiety.!

II"1! 20!minutes!for!some!effects,!20"30!minutes!!daily!for!90!days!typically!recommended.!

No!certification!required.!

Anywhere.!

Fast"Paced!Breathing!

Group,!individual!or!self"instruction!with!or!without!multi"media!aid,!10"30!mins.!daily.!

Accelerate!breathing!as!a!way!to!increase!focus,!energy!and!autonomic!arousal.!

III! Unknown.! No!certification!required.!

Anywhere.!

Warrior!Breath!(SKY)!

Small!group!format.!3"4!hrs.!!daily!for!6"7!days.!

Strengthens!parasympathetic!(vagal)!tone.!Increases!alertness!and!decreases!feelings!of!anxiety!and!depression.!

II"2! 30"60!minutes!for!some!effects,!30!minutes!for!60!days!is!recommended.!

Completion!of!SKY!1!&!2!(2"3!full!days!each).!!Supervised!SKY!trainings.!!

SKY!is!likely!best!suited!for!CONUS!operations.!It!has!not!been!tested!in!theater.!

Diaphragmatic!breathing!

Group,!individual!or!multi"media!format.!20!minutes!daily.!

Reverse!shallow!chest!breathing!associated!with!anxiety!and!hyper"arousal!to!increase!feelings!of!calm!and!relaxation.!!

II"1! Unknown.! No!certification!required.!

Anywhere.!

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USPSTF!Grades!of!Evidence!(Adapted!from!AHRQ,!2010)62!Grade! Level!Of!Evidence!Rating!Descriptions!

I! Evidence!obtained!from!at!least!one!properly!randomized,!controlled!trial.!II"1! Evidence!obtained!from!well"designed!controlled!trials!without!randomization.!

II"2!Evidence!obtained!from!well"designed!cohort!or!case"control!analytic!studies,!preferably!from!more!than!one!center!or!research!group.!

II"3!Evidence!obtained!from!multiple!time!series!with!and!without!the!intervention.!Dramatic!results!in!uncontrolled!experiments!(such!as!the!results!of!the!introduction!of!penicillin!treatment!in!the!1940s)!could!also!be!regarded!as!this!type!of!evidence.!

III!Opinions!of!respected!authorities,!based!on!clinical!experience;!descriptive!studies!and!case!reports;!or!reports!of!expert!committees.!

!In!summary,!more!studies!comparing!the!effects!of!breathing!practices!as!well!as!the!varying!mechanisms!of!action!and!physiological!and!cognitive!impacts!are!needed!to!understand!how!best!to!use!breathing!practice!to!bring!about!desired!emotional!and!arousal!states.!Standardized!measures!for!comparing!a!technique’s!impact!on!ANS!functioning!would!prove!valuable!for!determining!the!strength!of!findings!for!each!of!the!breathing!techniques!reviewed!and!their!comparative!effectiveness.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

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POSTURE!AND!TENSION"MODULATION!TECHNIQUES!FOR!ANS!REGULATION!

Stress!and!anxiety!are!reflected!in!the!body!in!numerous!ways.!Basic!physiological!responses!to!stress!include!changes!in!the!relative!activity!of!the!sympathetic!and!parasympathetic!nervous!systems,!such!as!in!the!extreme!fight!or!flight!response,!during!which!the!pupils!dilate!and!cortisol!production!increases.!Much!research!has!been!dedicated!to!study!the!effects!of!stress!on!emotion!and!behavior!and!how!this!is!encoded!in!facial!expressions,!postures!and!muscle!stiffness.63!Some!compelling!lines!of!research!seek!to!relate!certain!physical!postures,!pressure!points!and!patterns!of!physical!activity!to!emotional!states.!Conversely,!compelling!research!relates!how!one!might!use!postures!and!physical!movements!to!create!specific!emotional!states!that!can!be!measured!via!ANS!activity!(reciprocity).!One!classic!example!is!the!use!of!voluntary!facial!expressions,!such!as!smiling,!resulting!in!ANS!activity!associated!with!happiness.64"66!!

!For!thousands!of!years,!various!mind"body!techniques!have!been!used!in!different!cultures!to!treat!and!maintain!physical!and!mental!health.!In!recent!years,!researchers!have!begun!trying!to!quantify!the!effects!of!several!of!these!practices!with!modern!biological!measuring!devices.!Body"focused!techniques,!such!as!yoga!and!muscle!manipulation!therapies,!have!been!studied!as!effective!standalone!or!adjunctive!treatments!for!stress!and!anxiety!disorders.7,37,67!!There!are!multiple!theories!to!account!for!perceived!positive!effects!of!yoga!and!stretch!exercises!on!stress!and!anxiety.!Stretch!exercises!are!thought!to!help!mitigate!accumulated!stress!hormones!and!as!well!as!reverse!stress!postures!and!anxiety!postures.68!Yoga!and!body"based!techniques!may!also!serve!as!a!kind!of!mindfulness!exercise!that!serve!to!build!awareness!of!symptoms!of!stress!in!the!body!while!distracting!the!mind!away!from!stress"evoking!thoughts.!Lastly,!it!is!theorized!that!whereas!cardiovascular!exercise!is!thought!to!regulate!SNS!more!strongly,!techniques!such!as!yoga!and!other!tension"modulation!exercises!may!have!a!greater!influence!on!the!PNS.69!!Below!is!a!more!detailed!description!of!yoga!as!well!as!promising!tension!release!exercises.!!Yoga!Most!yoga!practices!combine!three!elements:!physical!poses!(asanas),!controlled!breathing!and!a!short!period!of!deep!relaxation!or!meditation!at!the!end!of!the!yoga!treatment.!Reviews!of!yoga!practice!suggest!that!yoga!can!reduce!the!impact!of!exaggerated!stress!responses!and!may!be!helpful!for!both!anxiety!and!depression.37,67,70!In!terms!of!the!psycho"physiological!effects!of!yoga,!emerging!research!indicates!that!yoga!may!influence!PNS!tone!and!decrease!stress!hormones.36,37,67!Moreover,!some!research!suggests!that!back"bends!and!other!chest"opening!postures!may!be!particularly!effective!at!countering!postures!associated!with!depression!and!anxiety,!as!these!postures!have!been!found!to!be!particularly!associated!with!positive!mood!states.71!!!

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In!2004,!Khalsa!conducted!a!meta"analytic!review!of!181!research!articles!on!yoga"based!techniques!for!the!treatment!of!medical!or!psychiatric!conditions.!Khalsa!concluded,!“A!general!feature!of!these!practices!is!their!capability!of!inducing!a!coordinated!psycho"physiological!response,!which!is!the!antithesis!of!the!stress!response.!This!‘relaxation!response’!consists!of!a!generalized!reduction!in!both!cognitive!and!somatic!arousal!as!observed!in!the!modified!activity!of!the!hypothalamic!pituitary!axis!and!the!autonomic!nervous!system.”37!Khalsa!reported!at!least!eight!studies!that!indicate!that!yoga!“represents!deep!relaxation!of!the!autonomic!nervous!system!without!drowsiness!or!sleep!and!a!type!of!cerebral!activity!without!highly!accelerated!electrophysiological!manifestation.”37!Khalsa’s!review,!however,!did!not!describe!methods!used!to!demonstrate!a!connection!between!yoga!practices!and!ANS!regulation,!nor!did!the!review!include!a!description!of!which!yoga!practices!and!poses!might!prove!most!beneficial!for!regulating!the!ANS.!!!!A!second!meta"analysis!of!eight!published!clinical!studies!that!tested!yoga!as!an!intervention!with!respect!to!anxiety!and!anxiety!disorders!conducted!by!Kirkwood!et!al.67!!supported!the!use!of!yoga!for!the!reduction!of!symptoms!of!anxiety!and!obsessive!compulsive!disorder,!indicating!that!yoga!may!be!useful!to!help!bring!balance!to!the!ANS,!particularly!for!individuals!prone!to!anxiety!or!hyper"arousal.!While!studies!are!intriguing,!unfortunately!many!of!the!studies!reviewed!in!their!meta"analysis!contained!low!sample!sizes!and!methodological!inadequacies,!rendering!the!conclusiveness!of!such!findings!uncertain.67!!!!Though!evidence!directly!testing!a!connection!between!the!ANS!and!yoga!is!very!limited,!in!a!study!of!healthy!elderly!people!the!effects!of!asana!yoga!postures!as!well!as!yoga!breath!techniques!(including!the!SKY!breath!technique)!were!compared!to!aerobic!exercise!training.72!!Study!results!found!that!those!who!received!6!weeks!of!yoga!training,!3!hours!per!week,!had!a!significant!increase!in!heart!rate!variability!and!vagal!tone!compared!to!those!in!the!aerobic!activity!group.72!Study!results!suggest!that!yoga!may!be!more!effective!than!aerobic!exercise!at!influencing!the!PNS,!and!may,!for!this!reason,!prove!especially!beneficial!for!regulating!stress!and!mood,!even!in!non"anxious!populations.72!!In!addition!to!these!findings,!other!studies!similarly!indicate!that!yoga!holds!potential!for!positively!regulating!arousal!as!indicated!by!changes!in!heart!rate!variability,73,74!as!well!as!feelings!of!depression.74!Due!to!small!sample!sizes!and!poor!study!design!in!much!of!the!research!surveyed,!however,!more!studies!are!needed!to!validate!these!findings.!Despite!its!widespread!use!in!stress!reduction,!no!large"scale!clinical!trial!has!been!conducted!of!the!practice!of!yoga!for!managing!symptoms!of!anxiety!associated!with!PTSD.!In!theory,!because!PTSD!is!associated!with!physiological!arousal!and!decreased!heart!rate!variability,!it!is!likely!that!yoga!could!be!an!effective!treatment!of!the!emotion!control!difficulties!that!often!accompany!PTSD.!!From!one!individual!patient’s!perspective,!if!yoga!(or!any!other!integrative!practice)!reliably!produces!a!relaxation!response,!then!it!is!reasonable!to!consider!its!use!as!an!augmentative!strategy!to!help!with!modulating!hyperarousal!symptoms.5!!

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Yoga!is!now!offered!widely!in!civilian!as!well!as!veteran!and!active"duty!medical!and!community!settings.!Instruction!typically!lasts!from!60!to!90!minutes,!and!a!course!typically!requires!once!per!week!practice!for!6"8!weeks.!Certification!for!yoga!instruction!varies!greatly!depending!on!the!instructor’s!rate!of!learning!and!the!type!of!yoga!taught.!Typically,!yoga!teacher!training!programs!require!at!least!200!to!500!hours!of!training!prior!to!certification.!Non"healthcare!professionals!are!eligible!to!train!as!instructors.!!

!In!summary,!despite!indications!that!yoga!may!be!useful!for!regulating!emotional!states!such!as!anxiety!and!depression,!as!well!as!arousal,!more!studies!are!needed!to!validate!findings!in!a!more!systematic!manner.!In!addition,!few!studies!have!been!conducted!to!examine!the!neurobiological!mechanisms!that!may!be!relevant!to!Yoga’s!impact!on!the!ANS.!Additionally,!the!differential!benefits!and!emotion!impact!of!specific!yoga!poses!have!not!yet!been!adequately!studied,!nor!is!it!clear!how!much!yoga!practice!is!needed!to!achieve!beneficial!results.!It!is!possible,!as!an!example,!that!a!subset!of!yoga!posture,!such!as!back!bends!or!chest!opening!exercises,!may!primarily!account!for!some!of!the!positive!relaxation!and!anxiety!reduction!benefits!of!yoga!that!have!been!observed.!Lastly,!in!order!to!more!fully!assess!the!effectiveness!of!various!yoga!poses,!studies!are!needed!to!control!for!potential!confounding!factors!of!typical!yoga!routines.!More!specifically,!because!most!yoga!practices!combine!physical!poses!(asanas)!with!controlled!breathing!exercises!as!well!as!a!short!period!of!deep!relaxation!at!the!end!of!the!yoga!treatment,!studies!that!investigate!the!therapeutic!impact!of!traditional!yoga!will!not!be!able!to!determine!which!component!of!the!practice,!and!specifically!whether!the!asana!postures!themselves,!account!for!positive!findings.!!!!Trauma!Resiliency!Model!(TRM)!The!Trauma!Resiliency!Model!(TRM)!is!a!biologically"based!treatment!primarily!designed!to!target!the!body’s!reflexive!and!defensive!ways!of!responding!to!fear!and!associated!hyper"arousal!of!the!SNS.!The!body’s!responses!to!fear!are!targeted!primarily!through!increasing!body!awareness!during!times!of!arousal!and!anxiety!and!working!to!reverse!the!body’s!engrained!and!automatic!fear!responses.!TRM!was!inspired!by!Jane!Ayres’!Sensory!Integration!Theory,!Dr.!Eugene!Gendlin’s!Focusing,!and!Dr.!Peter!Levine’s!Somatic!Experiencing!(SE)!model.!TRM!is!based!on!the!theory!that!responses!to!threats!are!biologically!based!and!primarily!autonomic!and!that!cognitive!and!psychological!aspects!of!trauma!arise!secondary!to!biological!responses!to!fear.!In!line!with!this!theory,!TRM!treatment!posits!that!when!clients!learn!to!stabilize!the!physiological!symptoms!of!trauma!and!anxiety,!the!emotional,!cognitive!and!behavior!manifestations!of!trauma!symptoms!are!also!reduced.!The!approach!asserts!that!when!TRM!skills!are!learned!and!the!nervous!system!is!rebalanced,!more!traditional!talk"based!approaches!to!trauma!treatment!may!be!more!effective!because!the!brain!is!less!likely!to!be!hijacked!by!physiological!aspects!of!anxiety!(E.!Miller"Karas!&!L.!Leich,!personal!communication,!July!16,!2010).!!

!TRM!training!sessions!teach!concrete!skills!to!reduce!hyper"!and!hypo"arousal!and!employ!a!methodology!that!emphasizes!tracking!sensations!in!the!body!associated!with!stressful!or!

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traumatic!memories!as!well!as!those!associated!with!uplifting!or!calming!memories!or!thoughts.!Shifting!between!awareness!of!these!two!opposite!physical,!emotional!and!physiological!states!is!thought!to!help!restore!the!body’s!natural!balance!between!the!sympathetic!and!parasympathetic!branches!of!the!autonomic!nervous!system.!While!in!this!“Resilient!Zone,”!service!members!are!taught!to!restore!balanced!functioning!of!thoughts,!feelings!and!physiological!responses!to!stressful!or!traumatic!triggers.!TRM!training!also!includes!a!skill!to!complete!defensive!gestures!or!postures!of!fight!and!flight!that!were!thwarted!during!the!traumatic!event.!! !TRM!treatment!can!be!used!in!individual,!group!and!community!settings.!It!was!first!developed!for!use!by!crisis!care!workers!to!help!victims!who!have!been!faced!with!natural!disasters!and!catastrophic!events.!It!has!more!recently!been!adapted!to!help!treat!veterans!with!PTSD!and!veterans!with!trauma!and!co"morbid!pain!management!difficulties!(in!a!variant!of!the!treatment!known!as!“the!Trauma!Resiliency!Model!"!Veterans!&!Warriors.”)!!TRM!is!also!currently!being!used!in"theater,!but!has!not!yet!been!formally!studied!for!use!in!this!context!(E.!Karas!&!L.!Leich,!personal!communication,!July!16,!2010).!TRM!is!offered!in!two!levels!and!requires!3!days!of!training!at!each!level.!!TRM"C,!the!version!of!TRM!that!focuses!on!creating!resiliency"informed!communities,!uses!five!of!eight!TRM!skills!taught!and!is!designed!for!use!by!non"clinicians!such!as!peer"to!peer!counselors!and!military!chaplains.!!Once!learned,!TRM!skills!can!be!self"practiced!via!smart!phones!through!an!application!titled!iChill.!More!specifically!iChill!provides:!1)!information!on!the!biology!of!trauma!and!its!impact!on!the!autonomic!nervous!system;!2)!step"by"step!TRM!stabilization!skills;!and!3)!allows!the!individual!to!rate!how!‘resourced’!or!calm!they!feel!following!skill!practice.!The!application!also!allows!users!to!input!voices!of!loved!ones!as!well!as!photos!that!evoke!positive!or!relaxing!(i.e.,!PNS"evoking)!emotions!to!help!balance!ANS!hyper"activity.!The!effectiveness!of!the!iChill!application!is!currently!being!piloted!with!a!small!group!of!deployed!Army!chaplains!(E.!Miller"Karas,!personal!communication,!December!21,!2010).!The!application!and!results!of!the!study!are!due!for!release!in!2011.!!In!terms!of!research!to!support!TRM,!following!hurricane!Katrina,!Leitch,!Vanslyke!and!Allen75!compared!coping!capacity!and!trauma!symptoms!across!91!disaster!agency!workers!who!were!taught!TRM!skills!and!51!agency!workers!who!did!not!receive!any!training.!Study!results!indicated!that!agency!workers!who!received!TRM!training!had!fewer!PTSD!symptoms!up!to!3!and!4!months!following!assessment!than!did!the!non"treatment!group.!In!terms!of!future!research,!Dr.!Tara!Victor,!a!therapist!at!the!Veterans!Affairs!Medical!Center!of!Los!Angeles,!CA,!is!currently!piloting!TRM!as!a!group!therapy!for!patients!with!co"morbid!chronic!pain!and!PTSD!(personal!communication,!June!23,!2010).!In!an!interview,!Dr.!Victor!explained!that!in!addition!to!self"assessment!measures!to!track!pain!and!trauma!symptoms,!she!plans!to!collect!biological!data!and!autonomic!indicators!(i.e.,!heart!rate!variability!and!skin!conductance)!(personal!communication,!June!20,!2010).!Study!results!are!due!to!be!completed!in!the!summer!of!2011.!!

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!Trauma/Tension!Releasing!Exercises!(TRE)!:!TRE’s!are!a!brief!series!of!techniques!designed!to!produce!trauma!healing!and!stress!reduction!by!using!six!simple!exercises!that!evoke!neuromuscular!tremors/shaking!that!is!generally!experienced!as!relaxing!or!pleasurable.76!!It!is!believed!that!when!evoked,!the!tremors!begin!to!release!deep!chronic!muscular!tension!held!within!the!core!(psoas!muscle,!paraspinal!muscles,!abdomen,!etc.),!or!“energetic!center,”!in!the!body.!When!tremors!are!evoked,!which!generally!occurs!within!15!minutes,!the!shaking!is!observed!to!reverberate!throughout!the!body,!often!beginning!in!the!legs!and!pelvis,!and!traveling!to!other!areas!of!the!body!releasing!deep!chronic!tension!throughout.!TRE!has!been!taught!to!U.S.!military!personnel!prior!to!deployment!with!the!intent!of!their!being!able!to!use!it!to!modulate!ANS!during!deployment.!!!!!!TRE!holds!appeal!because!the!techniques!can!be!easily!self"taught!through!a!short!instructional!video!or!one"two!hour!workshop,!and!individuals!who!practice!the!technique!report!immediate!anxiety!and!muscular!tension!relief.!The!technique!is!easily!reproducible!and!most!who!try!the!exercises!experience!the!neurotremor!release.!The!technique!was!discovered!through!observing!the!natural!tremors/shaking!response!that!can!occur!immediately!after!traumatic!events.!!For!some,!it!is!recommended!the!technique!be!used!in!conjunction!with!therapy!because!it!may!release!emotions!and!memories!associated!with!past!trauma.!However,!according!the!TRE!founder,!the!neurotremor!response!is!generally!experienced!as!pleasurable,!is!under!the!individual’s!control,!and!can!be!stopped!by!the!individual!at!any!time.!!!Although!no!research!investigating!the!efficacy!of!TRE!exists,!it!appears!promising!for!its!ease!of!use,!reducing!hyper"arousal!and!multiple!anecdotal!reports!of!its!immediate!benefit,!including!those!from!military!personnel!(http://traumaprevention.com).!Further!research!into!the!technique!is!merited.!!!!!The!developer!of!TRE,!David!Berceli,76!recommends!as!a!precaution!that!TRE!not!be!used!in!people!who!are!pregnant!or!have!a!history!of!a!seizure!disorder.!Although!there!are!no!specific!reports!of!harm!in!these!or!other!conditions,!TRE!is!not!recommended!for!individuals!with!seizure!disorders!or!for!those!who!are!pregnant.!!TRE!has!been!used!in!large!military!populations!as!well!as!large!traumatized!civilian!populations!exposed!to!natural!or!war"related!disasters.!Given!a!relative!lack!of!research!using!biological!measures!to!study!the!effects!of!tension!release!exercises,!theories!as!to!how!tension!release!practices!affect!the!ANS!remain!unknown.!The!reproducible!nature!of!TRE!raises!the!level!of!interest!in!understanding!what!the!mechanism!is!of!the!neuromuscular!tremor!response.!!!!Conclusions!and!Future!Areas!of!Research!!Research!correlating!clinical!and!self"reported!outcomes!with!biological!measures!is!needed!to!gain!a!better!understanding!of!the!ways!in!which!specific!body"based!practices,!such!as!!yoga!and!TRE!might!differentially!affect!mood!and!arousal.!A!relatively!small!amount!of!research!exists!involving!randomized!controlled!studies!to!demonstrate!effectiveness.!Moreover,!very!few!studies!have!been!done!to!determine!which,!if!any,!specific!postures,!areas!in!the!body,!or!movements!may!prove!particularly!beneficial!for!releasing!trapped!

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stress,!enhancing!energy!or!reversing!anxiety!postures.!Finally,!because!most!body"based!practices!reviewed!require!individuals!to!concentrate!attention!on!the!body!during!practice,!or!contain!other!potentially!therapeutic!adjuncts!to!practice,!it!remains!difficult!to!rule!out!whether!positive!benefits!documented!are!attributable!to!other!aspects!of!a!training!program.38!!!Despite!the!fact!that!biological!mechanisms!have!not!yet!been!fully!understood,!evolving!research!indicates!that!body"based!techniques!such!as!asana!yoga,!TRE!and!TRM!may!help!regulate!stress!hormones,!relax!postural!tensions,!and!!affect!physiological!states!associated!with!chronic!stress!and!anxiety,!ultimately!proving!helpful!for!restoring!homeostasis.!Table!2!provides!a!summary!of!body"based!techniques!reviewed!as!well!as!their!differential!features!and!mechanisms!of!action.!!Table!2.!Comparative!Summary!of!Posture!and!Tension"Modulation!Practices!!

Program!or!Model!

Training!features! Proposed!Mechanisms!and!Goals!

Evidence!Rating!

Practice!Features!

Trainer!Requirements!

Practice!Settings!

TRM! Small!group!format,!3!full!days;!modified!TRM!being!piloted!for!individual!and!group!therapy.!!

Restore!ANS!balance!by!detecting!and!reversing!physiological!responses!to!trauma!reminders.!Used!to!reduce!reactivity!to!trauma!reminders.!!

II"1! 7"14!days!for!some!effects,!15!min.!of!daily!practice!while!anxious!is!recommended.!

Successful!completion!of!TRM!1!&!2!+!four!!supervised!TRM!trainings.!!

TRM!is!currently!being!practiced!in!CONUS,!O"CONUS!and!in!theater.!!!

TRE! Can!be!trained!in!short!period!(e.g.!2!hour!workship),!can!also!be!achieved!through!self"instruction!!50!minute!DVD!or!book.!

Discharging!trapped!stress!by!inducing!tremors!in!muscle!groups.!Used!to!reduce!anxiety!and!trauma!symptoms.!!

III! Effects!are!reported!to!be!immediate.!

Certificationprocesses!available!through!TRE!organization!

Anywhere.!

Yoga!(Asana)!Postures!

Small!group!format,!1"2!hour!sessions.!

Discharge!trapped!stress,!reverse!stress!postures!that!maintain!anxiety.!Yoga!can!be!used!to!decrease!stress,!anxiety,!depression!and!increase!feelings!of!relaxation.!!

I! Some!immediate!relief!anecdotally!reported.!Recommended!practice!length!is!variable.!!

Months!to!years!depending!on!trainer!and!type!of!yoga!taught.!

Yoga!is!best!suited!for!CONUS!operations.!Yoga!has!not!been!tested!for!in!theater!use.!

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USPSTF!Grades!of!Evidence!(Adapted!from!AHRQ,!2010)62!Grade! Level!Of!Evidence!Rating!Descriptions!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

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MINDFULNESS,!MEDITATION!AND!GUIDED!IMAGERY!

With!roots!in!both!eastern!and!western!religions,!particularly!buddhism,!mindfulness!is!a!practice!to!gain!awareness!in!the!present!moment.!Multiple!definitions!of!mindfulness!have!prevented!a!clear!understanding!of!the!term!and!have!also!hindered!research!progress.77!An!increasingly!utilized!definition!arrived!at!by!an!interdisciplinary!team!of!researchers!concluded!that!most!mindfulness!practices!contain!two!components:!self"regulation!of!attention!and!a!noticing!as!well!as!“acceptance”!of!present"moment!experiences,!to!include!the!acceptance!of!unpleasant!experiences!and!unpleasant!emotions.77!In!mindfulness,!the!ability!to!regulate!attention!is!typically!developed!through!practicing!sustaining!attention!on!the!present!moment!through!focusing!attention!on!a!particular!stimulae,!such!as!the!breath.78!In!contrast,!the!!“acceptance”!component!of!mindfulness!typically!involves!noticing!and!accepting!internal!and!external!sensations!as!they!arise!in!the!present,!“rather!than!judging,!ignoring!or!minimizing!them,!particularly!when!they!are!unpleasant.”78!!!!An!underlying!principle!behind!mindfulness!practice!is!that!our!most!stressful!and!distressing!thoughts!are!those!that!are!too!narrowly!focused!and!heavily!fixated!on!past!events!or!on!desired!or!feared!future!states.!As!such,!through!learning!to!more!fully!attend!to!and!accept!sensations!in!the!present!moment,!negative!emotions!can!be!mitigated!and!a!broader!range!of!possible!solutions!to!problems!might!be!found.79,80!It!has!been!hypothesized!that!through!mindfulness!practice,!individuals!can!learn!over!time!to!respond!to!stressful!situations!more!flexibly!and!adaptively,!as!opposed!to!turning!“unconsciously”!or!“reflexively”!to!habitual!thoughts!and!behaviors!that!may!not!always!be!the!most!adaptive!to!presenting!demands.80!!!!A!systematic!review!of!311!studies!examining!the!impact!of!mindfulness!and!meditation!techniques!commissioned!by!the!U.S.!National!Center!for!Complementary!and!Alternative!Medicine!(NCCAM)!and!the!U.S.!Agency!for!Healthcare!Research!and!Quality!(AHRQ)!titled!“Meditation!practices!for!health:!State!of!the!research,”38!!provides!an!analytic!review!of!seven!sub"types!of!mindfulness.!!The!report!concludes!that,!across!types!of!mindfulness!practice,!there!is!a!substantial!amount!of!research!to!indicate!that!mindfulness!may!be!effective!in!reducing!heart!rate!as!well!as!depression,

!anxiety,!panic!disorders,!binge!eating!

disorders!and!substance!abuse.38!Despite!many!seemingly!positive!bi"products!to!mindfulness!practice,!however,!the!authors!caution!unreserved!reliance!on!findings!due!to!methodological!flaws!found!in!many!areas!of!mindfulness!research.38!!A!more!!and!recent!meta"analysis!of!mindfulness80!is!more!assertive!in!its!claims!about!the!benefits!of!mindfulness.!Results!of!a!meta"analysis!focusing!only!on!well"designed!studies!selected!using!strict!cut"off!criteria,!concluded!that!mindfulness!practice!is!effective!for!reducing!anxiety!and!depression.80!

In!addition!to!the!mood!benefits!of!mindfulness,!there!is!some!indication!that!over!time,!mindfulness!practice!can!help!foster!new!patterns!of!thought!as!indicated!by!increased!neuroplasticity!and!cognitive!flexibility.81!Finally,!there!is!some!indication!that!mindfulness!

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practice!can!help!strengthen!attention!control!and!working!memory!as!well!as!increase!positive!affect.33!More!studies!are!needed!to!conclusively!determine!these!promising!cognitive!benefits!of!mindfulness!practice.!

!The!“relaxation!response”!is!a!term!coined!by!Harvard!cardiologist!Herbert!Benson82!to!refer!to!the!body’s!natural!state!of!relaxation,!the!opposite!of!the!hyperactivity!of!the!nervous!system!associated!with!the!fight"or"flight!response.!Benson!believed!that!all!ancient!meditation!practices!are!capable!of!producing!the!“relaxation!response”!and!promote!a!decrease!in!sympathetic!nervous!system!activity.83!He!argued!that!the!particular!mindfulness!technique!used!may!not!particularly!matter!when!it!comes!to!experiencing!the!positive!benefits!of!practice.!!!!In!a!recent!study!examining!the!potential!“active!ingredients”!across!mindfulness!practice,!Coffey,!Hartman!and!Fredrickson,78!helped!elucidate!what!specific!“mechanisms!of!action”!might!account!for!Benson’s!finding!that!multiple!mindfulness!practices!appear!capable!of!producing!a!beneficial!response.!Specifically,!they78!concluded!that!in!contrast!to!attention!regulation,!the!“acceptance”!component!of!mindfulness!!practice!is!more!strongly!correlated!with!the!ability!to!regulate!negative!affect!!(to!include!anxiety!and!depression)!than!is!the!attention!regulation!aspect!of!mindfulness.78!The!authors!note!that!while!all!forms!of!mindfulness!practice!contain!an!attention"control!practice!component,!not!all!forms!of!mindfulness!contain!an!“acceptance”!component,!or!instructions!to!accept!and!notice!whatever!internal!experiences,!to!include!negative!experiences!and!emotions,!arise!non"judgmentally.38,78,84!The!Coffey!et!al78!study!results!are!potentially!important!in!that!they!indicate!that!mindfulness!trainings!that!emphasize!only!attention!control,!but!fail!to!teach!trainees!to!notice!and!allow!whatever!sensations!(particularly!negative!sensations!and!emotions)!may!arise!during!mindfulness!practice!may!not,!in!fact,!be!effective!for!mood!regulation.!!Their!study!postulates!that!being!able!to!fully!attend!to!and!accept!experiences,!particularly!unpleasant!ones,!is!a!first!and!critical!step!in!being!able!to!manage!emotional!reactions!to!challenging!life!situations.!!Due!to!the!fact!that!many!mindfulness!trainings!and!group!practice!sessions!are!fluid!and!interactive,!mindfulness!training!and!practice!may!be!influenced!by!qualities!in!the!trainer!(J.!Kabat"Zinn,!personal!communication,!September!4,!2010).!!As!such,!highly!skilled!communicators!and!skilled!trainers!who!teach!mindfulness!skills!may!be!more!likely!to!elicit!positive!results!than!less!skilled!communicators!or!trainers.!!With!this!said,!there!have!been!more!recent!attempts!to!create!more!protocol"driven,!or!standardized,!approaches!to!mindfulness!so!that!the!learning!of!mindfulness!is!less!dependent!on!qualities!of!the!instructor.!More!research!is!needed!to!determine!whether!it!is!possible!to!gain!some!of!the!same!positive!effects!using!such!a!protocol"driven!training!approach.!As!part!of!this!effort,!there!are!many!approaches!to!mindfulness!and!more!research!is!needed!to!identify!active!ingredients!of!tested!practices!as!well!as!the!variable!impact!of!components!of!practice.!!While!there!are!dozens!of!types!of!mindfulness!practice,!a!review!of!some!of!the!more!

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promising!mindfulness!and!meditation!practices!as!well!as!their!central!components!of!training!is!described!below.!!!Mindfulness"Based!Stress!Reduction!(MBSR)!Much!of!the!empirical!work!in!the!area!on!mindfulness!has!focused!on!the!program!developed!by!Jon!Kabat"Zinn,!called!Mindfulness"Based!Stress!Reduction!(MBSR).!MBSR!is!a!form!of!mental!training!that!involves!a!series!of!exercises!designed!to!help!practitioners!focus!awareness!on!present!experiences!and!return!the!attention!focus!to!the!target!of!attention!repeatedly!as!the!mind!becomes!distracted!by!other!objects!of!attention,!such!as!thoughts,!memories!or!plans!for!the!future.!The!mindfulness!component!of!the!program!incorporates!three!different!practices:!a!sitting!meditation,!Hatha!yoga!poses!and!a!body!scan/attention"regulation!exercise,!whereby!participants!are!instructed!to!sequentially!direct!attention!throughout!the!body.85!!The!foundation!for!the!practice!of!MBSR!is!the!cultivation!of!acceptance,!or!non"judgment!of!sensations,!emotions!and!thoughts!occurring!in!the!present!moment.!!The!MBSR!training!program!consists!of!an!8!week!intervention!with!weekly!classes!that!last!2"3!hours.!While!classes!contain!structured!content,!classes!are!also!designed!to!allow!room!for!dialogue!between!trainees!and!trainer!so!that!practice!questions!and!points!of!concern!might!be!discussed!and!resolved.!As!such,!MBSR!is!reliant!upon!skilled!trainers!who!are!well!versed!in!issues!that!might!arise!during!mindfulness!practice.!!There!is!also!typically!a!day"long!intensive!meditation!session!between!the!sixth!and!seventh!sessions.!Finally,!participants!complete!45"minute!sessions!at!home,!at!least!6!days!a!week!for!8!weeks.!!!Although!MBSR!is!primarily!designed!to!be!a!stress"reduction!training,!MBSR!Mindfulness!practice!has!been!found!to!aid!patients!with!anxiety!disorders.86!!Additionally,!MBSR!has!been!shown!to!increase!measures!of!positive!emotion!and!well"being,87,88!reduce!depressive!symptoms89,90!and!perceptions!of!stress!and!pain,91!as!well!as!improve!immune!function.87!!!Lastly,!behavioral!and!neuroimaging!studies!indicate!that!MBSR!mindfulness!practitioners!exhibit!greater!cognitive!flexibility,92!attention!resources93,94!and!emotion!regulation.94"96!All!of!these!skills!are!highly!relevant!to!PTSD!patients!who!often!suffer!self"regulatory!deficits!and!feelings!of!lack!of!control.97!Publications!also!suggest!that!MBSR!practitioners!are!better!able!to!direct!their!attention!and!concentration,!compared!to!non"practicing!controls.87!In!terms!of!possible!mechanisms!accounting!for!these!findings,!Davidson!et!al87!!found!increases!in!right!frontal!brain!activity!following!8!weeks!of!MBSR!training.!More!specifically,!participants!in!the!MBSR!group!showed!greater!increases!in!left"sided!resting!brain!activity!than!did!controls.!Increases!in!left"sided!activation!are!thought!to!be!associated!with!more!positive!and!adaptive!emotional!styles.87!!! !Mindfulness!Mind"Fitness!Training!(MMFT)!Mindfulness!Mind"Fitness!Training!is!promoted!as!a!stress!reduction!and!mission!enhancement!technique!that!trains!attention!control!and!body!awareness!in!a!similar!way!we!train!body!functioning!at!the!gym.!In!contrast!to!MBSR,!

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which!focuses!on!stress!reduction,!MMFT!is!specifically!designed!to!cultivate!greater!psychological!resilience!or!“mental!armor.”!!The!mindfulness!component!of!the!program!incorporates!four!different!practices:!!

!!1.!Focusing!attention!exclusively!on!a!single!object!!!2.!Enhancing!awareness!of!sensations!within!the!body!!!3.!Grounding!attention!to!the!body’s!contact!with!the!floor!or!chair!in!times!of!

emotional!distress!!4.!Learning!to!shift!attention!between!inner!experiences!and!outer!awareness!

!When!mindfulness!skills!have!been!mastered!to!deploy,!sustain!and!re"direct!attention,!MMFT!participants!are!then!taught!to!focus!attention!to!re"regulate!physiological!and!psychological!symptoms!that!develop!from!stressful!experiences.!!

!In!addition!to!mindfulness!practice!that!forms!the!basis!of!the!intervention,!service!members!that!undergo!MMFT!are!provided!with!education!about!the!biology!of!stress!and!anxiety.!Mindfulness!skills!are!framed!in!terms!of!their!potential!for!enhancing!operational!functioning!(e.g.,!situational!awareness!and!enhanced!working!memory)!and!mission!success.!Thus,!a!key!difference!between!MBSR!and!MMFT!is!that!while!MBSR!is!primarily!emphasized!as!a!stress!reduction!technique,!the!explicit!course!goal!of!MMFT!is!to!promote!stress!resilience!and!to!enhance!functioning!(specifically!working!memory,!attention!awareness!and!environmental!awareness)!during!times!of!high!anxiety!and!stress.!To!accommodate!often!large!numbers!of!trainees,!rather!than!being!interactive,!MMFT!is!a!more!classroom!"!and!“manualized”!or!protocol"driven!method!of!training.!!

!The!MMFT!course!has!been!taught!to!service!members!before!they!deploy!for!combat.!Training!requires!24!hours!of!classroom!training!over!8!weeks!(average!classroom!time!is!2!hours!per!session)!and!recommended!30!minutes!of!daily!practice!exercises!outside!of!class.!There!is!also!typically!a!day"long!intensive!meditation!session!in!the!8th!week.!

!Recent!studies!have!shown!a!positive!link!between!MMFT!and!improvements!in!mood!and!working!memory!in!a!high"stress!U.S.!military!group!preparing!for!deployment!to!Iraq.33!In!a!study!to!assess!the!effectiveness!of!MMFT,33!!31!male!Marine!reservists!were!provided!the!training!pre"deployment!and!effects!were!compared!to!17!Marines!in!a!second!group!without!training!as!a!control.!After!the!training!period,!both!groups!were!evaluated!in!terms!of!working!memory!(through!a!task!titled!Operation!Span!Task!that!involves!working!memory!function)!and!broad"based!positive!and!negative!affect!(using!the!Positive!and!Negative!Affect!Schedule!or!PANAS).!Study!results!found!that!working!memory!capacity!degraded!and!negative!mood!increased!over!time!in!the!control!group.!However,!working!memory!significantly!improved!and!negative!mood!decreased!in!those!who!underwent!MMFT!and!spent!extensive!practice!time!over!the!8"week!period.33!Further!randomized!control!studies!are!needed!to!validate!study!findings.!!

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Yoga!Nidra!Meditation!(iRest)!Although!many!forms!of!meditation!and!prayer!targeting!relaxation!exist,!for!this!paper,!only!Yoga!Nidra!(iRest)!was!reviewed.!Integrative!Restoration!Yoga!Nidra!Meditation,!or!iRest®,!was!derived!from!an!ancient!yoga!nidra!practice.!It!was!developed!by!psychologist!Dr.!Richard!Miller!over!the!last!28!years!for!clinical!use.!First!tested!by!the!Deployment!Health!Clinical!Center!at!Walter!Reed!Army!Medical!Center!in!2006!for!its!feasibility!as!an!adjunctive!modality!for!service!members!experiencing!PTSD,!iRest®!!is!now!being!successfully!used!in!many!VA!and!military!health!care!facilities!worldwide.!!!

!A!typical!iRest®!class!consists!of:!a!brief!check"in!with!students,!a!30!to!45!minute!guided!meditation!and!a!few!minutes!for!questions!at!the!end.!Classes!usually!run!between!60!and!75!minutes.!Home!practice!recordings!(CD!or!mp3)!are!used!in!all!research!and!treatment!settings![http://www.irest.us].!!The!iRest®!protocol!consists!of!10!sequential!stages!that!include!a!thorough!body!scan;!breathing!awareness;!systematic!neutralization!of!negative!emotions!and!beliefs;!and!development!of!the!capacity!to!experience!equanimity!amidst!the!changing!circumstances!of!life.!Instructors!are!trained!and!certified!to!administer!the!iRest®!protocol.!!!Participants!report!decreases!in!insomnia,!depression,!anxiety,!hyper"vigilance,!angry!outbursts!and!pain!and!increases!in!energy!level,!perceived!control!in!life,!and,!paradoxically,!acceptance!of!circumstances!beyond!their!control.!iRest®!may!be!particularly!well"suited!for!military!personnel!and!families!because!it:!!

! Is!a!non"pharmaceutical,!cost"effective!adjunctive!program!that!complements!any!current!treatments!they!are!using!for!healing!

! Develops!mental!focus!on!the!present!moment!which!helps!people!resist!the!urge!to!revisit!traumatic!life!events!or!worry!about!possible!future!ones!

! Emphasizes!the!practice!of!being!aware!of!and!non"judgmental!acceptance!of!immediate!as!well!as!past!experiences,!and!acceptance!of!life!as!it!is!without!excessive!tension!

! Quickly!establishes!a!feeling!of!success!in!learning!and!a!means!of!self"regulation!! Is!a!self"administered!program!after!just!a!few!hours!of!in"person!instruction!! Is!a!secular!program!suitable!for!all!age!groups!and!needs,!families!and!

caregivers!!

Although!iRest®!lists!that!research!projects!have!been!completed!at!The!Walter!Reed!Army!Institute!of!Research!(Active!Duty!and!PTSD);!Brooke!Army!Medical!Center!(BAMC):!(Compassion!Fatigue!&!Health!Care!Workers);!COTS!(Homelessness:!Anxiety,!Well"being);!Boise!State!University!(Multiple!Sclerosis);!Brooklyn,!New!York!(Chemical!Dependency);!and!University!of!Missouri!(College!Students:!Well"being),!the!results!are!unclear!given!that!only!the!multiple!sclerosis!study!was!published.!!!!

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Guided!Imagery!Guided!imagery,!also!called!“visualization”!and!“mental!rehearsal”!can!be!defined!as!imagining!an!experience!that!resembles!perceptual!experience.!Guided!imagery!techniques!can!be!practiced!alone!or!in!a!group!with!a!therapist’s!assistance,!or!it!can!be!self"practiced!using!an!audio!or!media!recording.!!Guided!imagery!is!used!for!a!variety!of!purposes!ranging!from!stress!relief,!pain!management,!performance!enhancement!and!treatment!of!a!variety!of!psychological!health!conditions!to!include!anxiety!and!PTSD.!!!There!are!many!techniques!used!in!the!area!of!guided!imagery.!!One!common!technique!consists!of!focusing!on!an!area!of!the!body!where!pain!or!emotional!distress!occur!and!picturing!pain!or!distress!as!an!image!(e.g.!a!shape!or!dial).!By!using!this!technique,!the!pain!or!distress!can!then!be!visually!manipulated!and!reduced!in!size!or!intensity!to!elicit!feelings!of!relief.!!Another!common!technique!involves!imagining!a!wise!person,!or!inner"guide,!who!can!help!reduce!feelings!of!loneliness!or!anxiety!as!well!as!help!provide!feelings!of!reassurance!and!healing.!When!used!as!a!relaxation!technique,!guided!imagery!often!involves!imagining!a!scene!that!brings!feelings!of!serenity!or!relaxation,!such!as!lying!on!a!sunny!beach.!A!final!common!technique,!used!most!commonly!in!meditation!practices,!is!to!have!individuals!meditate!on!images!of!inspiring!objects!or!religious!figures!as!a!way!to!help!inspire!or!uplift!lift!the!mind!as!well!as!to!move!it!away!from!negative!thinking!or!distress.!!!Brain!scans!have!indicated!that!imagery!can!stimulate!the!same!areas!of!the!brain!and!nervous!systems!as!the!true!!experiences!can.98"100!!It!has!also!been!stipulated!that!the!brain's!visual!cortex,!which!processes!images,!is!connected!to!the!autonomic!nervous!system.101!!!!!In!terms!of!evidence!supporting!the!use!of!guided!imagery,!a!meta"analytic!review!of!46!studies!suggest!that!guided!imagery!may!be!helpful!for!managing!stress,!anxiety,!depression!and!pain!management.102!!Many!of!the!studies!examined,!however,!combined!imagery!techniques!with!other!interventions!such!as!hypnosis,!cognitive"behavioral!therapy!and!relaxation!techniques,!making!it!difficult!to!definitively!conclude!that!guided!imagery!was!an!active!component!in!improvement.!!!Guided!imagery!has!also!been!used!in!sports!psychology!to!enhance!performance.!Feltz!and!Landers103!conducted!a!meta"analytic!review!examining!60!studies!in!which!mental!practice!was!compared!to!control!conditions.!The!review!concluded!that!mental!rehearsal!(or!mental!practice!using!imagery)!improved!performance,!though!consistently!less!so!than!actual!physical!practice.!As!an!illustration!of!findings,!a!randomized!control!study!conducted!by!Roure101!!examined!guided!imagery!and!its!impact!on!the!autonomic!nervous!system,!as!well!as!on!ball"passing!performance!among!volleyball!players.!ANS!functions!to!include!temperature,!heart!rate!and!respiratory!frequency!were!tested!both!during!mental!rehearsal!sessions!and!actual!practice.!Study!results!indicate!that!mental!imagery!induces!the!same!patterns!of!autonomic!response!that!physical!experiences!can,!but!to!a!lesser!degree!of!intensity.!!During!an!actual!volleyball!practice,!players!who!had!mentally!

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rehearsed,!displayed!more!balanced!autonomic!functioning!(i.e.,!were!calmer)!during!the!game!and!rated!significantly!better!on!performance!compared!to!the!control!group.!!!!Recent!research!indicates!that!guided!imagery!may!be!promising!as!a!treatment!for!PTSD.!In!a!randomized!controlled!trial!study!through!Duke!University!in!partnership!with!the!Durham!Veterans!Affairs!Medical!Center,!52!women!veterans!with!longstanding!military!sexual!trauma!experienced!a!significant!drop!in!PTSD!symptoms!following!6!weeks!of!a!guided!imagery!intervention!specifically!designed!to!treat!individuals!with!PTSD.104!!!The!audio!CD!used!in!the!intervention!was!created!in!partnership!with!Healthjourneys!(www.healthjourneys.com),!which!is!a!company!that!partners!with!research!centers!and!universities!to!develop!and!test!guided!imagery!programs.!Results!of!this!study!have!recently!been!submitted!for!publication!and!are!due!to!be!published!in!the!Summer!of!2011!(J.!Strauss,!personal!communication).!!Studies!examining!the!effectiveness!of!guided!imagery!as!a!treatment!for!PTSD!appear!to!hold!promise!but!require!more!research.!!!Mindfulness,!Meditation!and!Guided!Imagery!Techniques:!Conclusions!and!Future!Areas!of!Research!In!the!last!decade,!increasing!attention,!both!within!and!outside!the!military,!has!been!paid!to!the!potential!focus!and!emotion"control!benefits!of!mindfulness!and!meditation.!Despite!an!increase!in!interest,!there!remain!relatively!few!well"designed!randomized!control!studies!in!this!area.!Meta"analytic!studies!indicate!that!mindfulness!practice!may!be!effective!in!reducing!symptoms!of!anxiety!and!depression.!In!order!to!determine!suitability!for!large"scale!use,!there!is!a!need!for!more!studies!which!examine!protocol"driven!and!manualized!approaches!to!training.!Related!to!this,!there!is!a!need!for!more!studies!that!isolate!and!examine!the!effective!components!of!mindfulness!practice.!Lastly,!few!studies!have!been!done!to!examine!how!much!practice!is!needed!for!optimal!results,!and!no!studies!were!found!that!compare!the!relative!benefits!to!more!commonplace!health!practices!or!treatments!(e.g.,!exercise,!stress!inoculation!training,!cognitive!behavioral!therapy).!!Studies!are!needed!to!determine!the!optimal!length!of!training,!and!whether!brief!training!interventions,!which!would!be!much!more!acceptable!to!build!into!routine!military!training!practices,!can!have!similar!benefit!as!longer!training.!!!In!the!area!of!guided!imagery,!although!studies!examining!its!effectiveness!appear!promising!on!the!whole,!there!appears!to!be!a!need!for!more!specific!research!and!attention!to!factors!such!as!type!of!imagery,!type!of!task!and!type!of!practice.!!Table!3!provides!a!summary!of!mindfulness,!meditation!and!guided!imagery!techniques,!along!with!their!differential!features!and!mechanisms!of!action.!!!!!!!

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!Table!3.!Comparative!Summary!of!Mindfulness,!Meditation,!and!Guided!Imagery!Practices!!

Program!or!Model!

Training!Features!

Proposed!Mechanisms!and!Goals!

Evidence!Rating!

Practice!Features!

Practice!!Settings!

MMFT! Small!group!format,!2!hrs.!daily!for!8!weeks!(minimum!of!24!hrs.!total)!

Attention!control,!increased!cognitive!flexibility!and!executive!control.!May!enhance!working!memory.!

II"1! 30!mins.!daily!practice!for!8!weeks!is!recommended.!!

Certification!not!yet!offered.!

MMFT!is!best!practiced!in!CONUS!settings,!once!mastered,!it!may!be!practiced!anywhere.!

MBSR! Small!group!format,!2"3!hrs.!daily!for!8!weeks.!

Attention!control,!increased!cognitive!flexibility!and!executive!control.!Used!to!regulate!stress,!decrease!anxiety!and!depression.!Increases!positive!emotions!and!emotion!control.!

I! 45!mins.!daily!practice!is!recommended.!

Variable!depending!on!trainer.!Supervision!is!required.!

MBSR!is!best!practiced!in!CONUS!settings,!once!mastered,!it!can!be!practiced!anywhere.!

Yoga!Nidra!(iRest),!

Small!group!Instructor"led!10"day!training!for!inpatients,!90!mins.!per!day!over!a!span!of!3!weeks.!Day!patients!listen!to!CD!set!for!30"60!mins/day.!

Postulated!to!activate!the!PNS,!through!conscious!utilization!of!techniques!that!are!meditative!and!visualization"based.!Used!to!reduce!depression,!PTSD!and!anxiety.!May!increase!energy.!

II"1! 30"60!mins.!of!daily!practice!is!recommended.!Can!be!done!with!a!guided!CD!set.!

Trainers!can!be!certified!to!teach!iRest!after!Level!3!training!in!these!therapeutic!facilities.!

iRest!is!best!practiced!in!CONUS!settings.!Once!mastered,!it!can!be!practiced!anywhere.!

Guided!Imagery!

Group,!individual!or!self"administered!audio!format!for!25–!90!mins.!daily.!

Used!to!enhance!performance,!regulate!stress!and!pain!and!decrease!anxiety,!PTSD!and!depression.!Visualization!stipulated!to!activate!brain!and!ANS!in!same!way!real!experiences!can.!

I!! 30!mins.!of!daily!practice!for!8!weeks.!

N/A.! Anywhere.!

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!USPSTF!Grades!of!Evidence!(Adapted!from!AHRQ,!2010)62!Grade! Level!Of!Evidence!Rating!Descriptions!

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MIND"BODY!PROGRAMS!

It!is!likely!that!beneficial!effects!of!integrative!practices!can!be!maximized!and!accelerated!through!combining!techniques!that!are!potentially!effective!for!regulating!the!ANS.!A!scan!of!the!evidence!found!a!limited!number!of!programs!that!have!systematically!studied!outcomes.!!Two!examples!of!effective!integrative!programs!are!the!Center!for!Mind!Body!Medicine,!founded!by!Dr.!James!Gordon!and!the!Benson"Henry!Institute!for!Mind!Body!Medicine!at!Massachusetts!General!Hospital,!founded!by!Herbert!Benson,!MD.!!!Center!for!Mind"Body!Medicine!(CMBM)!Many!organizations!use!multiple!approaches!to!enhance!fitness!via!ANS!modulation.!These!include!vocational!and!community"related!wellness!centers,!gyms,!coaching!programs,!schools,!military!training!programs,!medical!systems!and!proprietary!programs.!The!degree!to!which!such!programs!attend!to!the!state!of!scientific!literature!varies,!as!do!the!programs!themselves.!!The!CMBM!is!an!example!of!a!proprietary!program!that!includes!training!for!professionals!wishing!to!conduct!a!“mind"body!medicine”!program,!as!well!as!for!those!seeking!to!engage!such!a!program!for!personal!growth.!Modalities!employed!in!this!program!include:!meditation,!guided!imagery!and!biofeedback!(using!bio"dots);!self"expression!in!words,!drawings!and!movement;!and!physical!exercise,!dance,!yoga,!and!Tai!chi.!Domains!of!psychological!fitness!targeted!are!adaptability,!readiness,!competence,!strength,!self"awareness,!self"assertion,!self"care!and!appropriate!behavior.!Domains!of!physiological!fitness!measured!include!heart!and!respiratory!rate,!blood!pressure!and!peripheral!temperature.!Exercises!demonstrate!how!guided!imagery!and!meditation!affect!bodily!states!and!how!movement,!dance,!yoga,!active!meditation!and!Tai!chi!affect!mental!states.!!CMBM!programs!are!designed!to!help!facilitate!a!state!of!calm!to!improve!decision!making!and!work!efficiency!through!mobilization!of!cognitive!resources!and!enhanced!intuition!for!better!problem"solving.!Programs!are!designed!for!professionals!and!laypersons.!The!CBMB!has!significant!experience!working!in!multinational!war!and!disaster!trauma!settings!and!has!generated!literature!with!regard!to!the!efficacy!of!its!training!programs!and!interventions.!!CMBM!has!published!numerous!papers!on!the!effects!of!its!approach!on!trainees,!health!care!professionals,!medical!students,!children!and!adolescents.36,105,106!!Research!has!shown!that!the!program!produces!highly!significant!improvements!in!mood,!decreases!in!stress,!a!greater!sense!of!professional!satisfaction!and!enhanced!feelings!of!optimism!and!hope.36,105,106!!It!is!not!yet!clear!how!much!practice!or!participation!is!needed!before!results!begin!to!become!noticeable,!but!several!CMBM!studies!indicate!improvement!after!participating!in!a!12"hour!course!series!(taught!for!1!hour!per!day!over!12!weeks!in!small!group!settings).!!!

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In!terms!of!training!features,!CMBM!skills!takes!place!in!small!group!settings!through!certified!course!instructors.!Initial!training!in!mind"body!skills!is!a!5!day,!8!hour!per!day!course.!Participants!interested!in!teaching!course!skills!or!in!continuing!with!practice!may!participate!in!an!advanced!training!program,!also!a!5!day!course,!3!months!after!the!initial!course.!Between!programs,!participants!receive!consultation!to!help!them!practice!the!skills!they!have!learned!on!their!own.!For!those!interested!in!becoming!certified!teaching!course!skills,!ongoing!supervision!begins!after!advanced!training!and!is!2!hours!per!week!in!10"week!cycles!(or!for!as!long!as!the!facilitator!leads!a!small!mind"body!skills!group).!!Gordon!and!colleagues36!conducted!the!first!ever!integrative!intervention!with!a!traumatized!population!in!a!study!involving!war!traumatized!adolescents!following!conflicts!in!Kosovo.!In!the!study,!82!adolescents!meeting!criteria!for!PTSD!according!to!the!Harvard!Trauma!Questionnaire!were!randomly!assigned!to!a!12"session!mind"body!group!program!or!a!wait"list!control!group.!Following!the!program,!the!number!of!students!exhibiting!symptoms!indicating!PTSD!was!significantly!reduced!from!100!to!18!percent!and!reduction!in!symptoms!was!maintained!at!a!3!month!follow"up.36!Research!indicates!that!similar!beneficial!effects!can!also!be!observed!in!adult!health!care!professionals.105!!The!CMBM!is!in!the!process!of!analyzing!findings!from!a!PTSD!study!conducted!in!Gaza.!Data!were!gathered!on!498!children!who!participated!in!mind"body!skills!groups!taught!by!38!Center"trained!health!professionals!in!Gaza!in!2007.!!

The!Benson"Henry!Institute!for!Mind!Body!Medicine!at!Massachusetts!General!Hospital!

Established!in!1989,!the!Mind/Body!Medical!Institute!(M/BMI)!was!founded!by!Herbert!Benson,!MD,!as!a!non"profit!scientific!and!educational!organization!dedicated!to!research,!teaching!and!the!clinical!and!public!health!application!of!integrative!mind"body!medicine!programs!with!a!focus!on!the!importance!of!self"care!through!the!use!of!vehicles!designed!to!elicit!the!relaxation!response!(RR).!In!December!2006,!M/BMI!integrated!with!Massachusetts!General!Hospital!(MGH)!as!a!thematic!center!and!became!known!as!The!Benson"Henry!Institute!for!Mind!Body!Medicine!(BHI).!Its!Director!is!Gregory!Fricchione,!MD!and!its!Director!Emeritus!is!Herbert!Benson,!MD.!!!!The!BHI!enhances!the!clinical!mission!of!MGH!by!making!mind"body!approaches!available!to!those!experiencing!stress"related!conditions.!The!BHI!plays!a!key!role!in!educating!MGH!caregivers!to!be!better!equipped!to!employ!mind"body!techniques!in!their!practices.!Education!efforts!in!other!settings!such!as!schools,!workplaces!and!in!the!military!are!also!a!large!part!of!the!work!of!the!BHI.!There!has!also!been!a!role!in!public!health!through!BHI"led!efforts!to!promote!health!and!well"being!and!to!reduce!the!behavioral!risk!factors!for!physical!and!mental!conditions.!The!BHI!is!working!to!improve!understanding!of!stress"related!diseases!by!forming!partnerships!with!many!hospital!disciplines!and!subspecialties!in!unique!research!efforts!to!uncover!the!mysteries!of!mind"body!effects!and!to!find!evidence"based!therapeutic!strategies.!!

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At!BHI,!people!are!initially!given!a!consultation!with!an!integrative!medicine!internist!who!then!refers!the!individual!based!on!their!profile!of!goals!and!needs!to!an!8!week!program!that!meets!once!a!week!for!1!#!hour!group!sessions.!There!are!follow"up!opportunities!for!booster!sessions,!to!meet!program!alumni!or!to!serve!as!peer!group!supporters.!Individual!integrative!mind!body!sessions!with!a!physician!or!nurse!practitioner!are!also!available.!The!program!itself!builds!on!a!foundation!of!RR!and!includes!mindfulness!training!to!also!include!cognitive!skills!training;!positive!psychological!approaches;!social!support!and!pro"social!behavior;!spiritual!connectedness;!and!nutrition!and!exercise!advice.!Yoga!is!also!offered!as!is!Tai!chi!and!qigong!with!acupuncture!being!planned.!!!The!BHI!group!program!as!outlined!above!is!called!the!Relaxation!Response!Resiliency!Program!(RRRP)!and!is!designed!to!build!skill!in!mind"body!approaches,!which!reverse!or!buffer!the!effects!of!an!activated!stress!system.!!Components!include!a!variety!of!methods!to!elicit!the!relaxation!response!(RR),!which!reduces!autonomic!hyper"responsiveness,!103!has!the!potential!to!reduce!oxidative!stress,104!activate!the!reward!and!motivation!circuitries,!restructure!the!brain’s!neural!pathways!toward!adaptive!networks,105"106!alter!gene!expression!profiles!in!peripheral!blood!mononuclear!cells,!and!reduce!activation!of!stress!pathways.107!!In!the!RR,!prefrontal!neural!pathways!are!engaged!to!build!cognitive!flexibility!toward!more!adaptive!beliefs!and!thoughts.!Additionally,!skill"building!strategies!in!support!of!recuperative!sleep,!aerobic!activity,!anti"oxidizing!compounds,!nutrition!and!key!ingredients!of!social!support!are!also!engaged!to!provide!greater!resilience.!!!Resilience!is!a!function!of!the!body’s!ability!to!mount!an!appropriate!response!sufficient!to!meet!a!physiologic!or!psychological!demand!and!to!terminate!this!response!when!no!longer!needed.!!Resilience!is!compromised!by!either!sustained!demands!on!the!body’s!limited!resources!or!by!a!lack!of!restorative!behaviors.!This!relationship!can!be!understood!through!a!simple!heuristic!equation:108!!!!!Resilience!=!Propensity!to!Health!+!Performance!!Stress!!Mind"body!approaches,!such!as!the!elicitation!of!the!RR,!not!only!bolster!resilience!but!also!limit!stress!to!ensure!a!balance!in!favor!of!health,!well"being!and!enhanced!performance.!The!BHI!stress!reduction!and!resiliency!enhancement!approach!has!been!shown!to!lead!to!better!health!outcomes.109"110!!The!BHI!has!been!involved!in!educational!programming!since!1989.!!Its!Educational!Initiative!(EI)!has!developed!a!Train"the"Trainers!Program!adaptable!for!use!in!educational!settings!from!Head!Start!to!Graduate!Schools!in!high,!middle!and!low"income!settings.!The!EI!model!involves!six!to!12!hours!of!training!plus!in"class!modeling!exercises!and!direct!student!work.!There!have!been!several!demonstration!projects!of!mind"body!approaches!including!RR/stress!reduction,!cognitive!skills!training,!nutrition!and!exercise.!The!EI!also!provides!a!program!geared!to!reduce!test!anxiety!and!improve!test!performance.!

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!The!BHI!provides!a!five!day!clinical!training!in!mind"body!medicine!three!times!per!year.!This!training!is!open!to!clinicians,!researchers!and!other!interested!individuals.!Clinicians!who!want!to!incorporate!the!BHI!approach!into!their!practices!are!required!to!take!extra!training!at!BHI!and!to!be!trained!by!BHI!group!leaders.!!!Clinicians!trained!by!BHI!in!this!way!are!providing!mind!body!interventions!in!the!U.S.!Army!oldier!Total!Fitness!Course!(now!called!Soldier!360)!in!units!stationed!in!Bavaria,!as!well!as!n!the!Boston!Red!Sox!Home!Base!Program!for!Returning!Veterans.!Si!

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BiofeedbackBecause!the!ANS!regulates!a!number!of!biological!processes,!measuring!biological!functions!regulated!by!the!ANS!can!indicate!arousal!levels!and!feedback!that!might!be!used!to!regulate!as!well!as!monitor!arousal.!!A!sample!of!portable!biofeedback!tools!listed!below!are!available!to!measure!and!monitor!the!following!ANS!functions:!!!!

" Temperature:!Biodots!(http://www.biodots.net/)!" Heart!Rate!Variability:!Heartmath!(http://www.heartmath.com)!" Pulse:!StressEraser!(http://stresseraser.com)!" Respiration:!(http://www.t2health.org/)!

!Researchers!have!begun!to!investigate!ways!in!which!biofeedback!devices!can!monitor!heart!rate!variability.!Heart!rate!variability!(HRV)!reflects!the!healthy!alternating!balance!of!sympathetic!and!parasympathetic!effects!and!increased!HRV!is!associated!with!improved!cognitive!performance.!Low!rate!variability!signals!an!imbalance!of!these!influences,!with!sympathetic!tone!generally!predominating.!!Epidemiologically,!low!HRV!has!been!associated!with!increased!mortality.107!!! !Individuals!can!be!trained!to!increase!the!degree!of!HRV!by!breathing!slowly,!starting!by!approximating!the!rate!that!reflects!respiratory!sinus!arrhythmia!(RSA),!about!six!breath!cycles/minute.!RSA!variation!is!attributed!to!the!natural!heart!rate!increase!during!inspiration,!when!alveolar!volume!is!maximized!and!increased!blood!circulation!takes!advantage!of!maximal!ventilation!(O2/CO2!exchange),!while!heart!rate!slows!through!expiration.!It!is!theorized!that!a!natural!resonant!frequency!exists!for!each!individual!at!which!respiration/heart!rate!variations!optimize!autonomic!self"regulation,!and!“If!this!model!is!correct,!it!identifies!meditational!pathways!responsible!for!many!“mind/body”!and!physical!disorders.”2!!While!individuals!can!purchase!inexpensive!HRV!monitoring!devices!and!train!to!increase!their!HRV,!others!may!be!introduced!to!them!as!part!of!treatment!programs!for!various!medical!or!psychiatric!conditions!(including!military!use!with!PTSD/TBI!patients),!or!for!performance!enhancement.!Treatment!and!enhancement!programs!integrate!HRV!training!with!other!modalities!designed!to!meet!clients’!primary!objectives.!!!!HeartMath!is!a!company!conducting!HRV!research,!developing!and!providing!HRV!biofeedback!training!(25,000!people!trained!yearly)!and!marketing!HRV!pocket!monitors,!software!and!issue"focused!training!materials.!Examples!of!specific!programs!include!HRV!training!for!stress!and!anger!management,!alleviation!of!depression,!control!of!hypertension,!improving!sports!performance,!optimizing!personal!performance!and!losing!weight.!!A!more!comprehensive!list!of!tools!for!monitoring!autonomic!activity!can!be!found!in!the!“Portable!ANS!Measurement!Tools”!table!in!Appendix!D.!

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Summary!and!Conclusion!

While!traditional!approaches!to!stress!management!have!relied!primarily!on!talk"based!or!cognitive"behavioral!approaches,!this!review!focuses!on!integrative!mind"body!practices!that!have!been!speculated!to!more!directly!manipulate!the!ANS!and!associated!biological!processes!to!achieve!greater!control!over!stress,!arousal!and!emotions.7!Techniques!that!appear!to!help!regulate!the!ANS!are!particularly!promising!for!regulating!stress,!arousal!and!mood.!!!The!ANS!has!two!branches:!the!SNS!and!the!PNS.!!These!branches!act!like!a!driver!choosing!between!pressing!the!accelerator!(the!sympathetic!branch)!and!bearing!down!on!the!brakes!(the!parasympathetic!branch).!Both!components!are!needed,!but!too!much!of!one!or!the!other!can!create!a!sudden!change!in!the!car’s!handling!and!speed.!When!the!accelerator!(SNS)!is!aroused!beyond!its!optimal!level,!feelings!of!fear!and!distress!predominate.!When!the!accelerator!(SNS)!is!not!aroused!enough,!the!car!moves!with!less!speed!and!agility.!In!more!scientific!terms,!hyper"arousal!of!the!SNS!can!lead!to!excessive!stress!and!anxiety,!which!can!impact!cognitive!functioning!(i.e.,!attention,!working!memory!and!processing!speed),!as!well!as!lead!to!more!performance!errors.!On!the!other!hand,!not!enough!SNS!activation!can!lead!to!sub"optimal!levels!of!arousal,!which!can!also!negatively!influence!attention,!performance!and!cognitive!functioning.!!!The!stress!that!occurs!from!an!over"activated!SNS!can!ultimately!be!controlled!by!applying!the!brakes!to!bring!harmony!between!speed!and!control.!The!brakes!(the!PNS)!act!as!an!inhibitor!of!automatic!responses!to!stress,!ultimately!allowing!for!better!control!over!arousal!and!emotions.!The!ability!to!tap!into!this!brake!mechanism!or!into!the!accelerator!pedals!was!the!primary!basis!of!the!discussion!in!this!review.!While!most!of!the!practices!reviewed!in!this!report!aim!to!lower!SNS!arousal!or!activate!the!PNS,!the!paper!also!surveyed!techniques!that!may!prove!promising!for!heightening!arousal!when!it!is!too!low.!!!Programs!were!surveyed!across!three!domains!of!integrative!wellness:!breathing!practices;!body"based!tension!modulation!exercises;!and!mindfulness,!meditation!and!guided!imagery!practices.!The!results!of!the!literature!review!suggest!that!a!number!of!practices!designed!to!enhance!autonomic!regulation!appear!promising!on!the!basis!of!either!their!proven!effectiveness,!practice!features,!trainability!to!individuals!and!non"licensed!professionals!or!potential!for!use!in!operational!settings.!A!sample!of!13!practices!within!these!three!domains!was!reviewed.!Program!features,!in!addition!to!comparative!advantages!and!disadvantages!of!the!13!mind"body!techniques!surveyed,!are!summarized!below!in!Table!4.!!!!!!

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Table!4.!Comparative!Summary!of!Mind"body!Health!Practices!Program!or!Model!

Training!features!

Proposed!Mechanisms!and!Goals!

Evidence!Rating!

Practice!Features!

Practice!Settings!

Slow"Paced!Breathing!

Group,!individual!or!self"instruction!with!multi"media!aid,!10"30!mins.!daily.!

Reverse!fast"paced!breathing!associated!with!anxiety!and!hyper"arousal.!Practice!is!thought!to!decrease!stress!and!anxiety!through!increasing!parasympathetic!tone.!

II"1! 20!mins.!for!some!effects,!20"30!mins.!per!day!for!90!days!is!recommended.!

No!certification!required.!

Anywhere.!

Fast"Paced!Breathing!

Group,!individual!or!self"instruction,!for!10"30!mins.!daily.!

Accelerate!breathing!as!a!way!to!increase!autonomic!arousal!as!well!as!energy!and!focus.!

III! Unknown.! No!certification!required.!

Anywhere.!

Warrior!Breath!(SKY)!

Small!group!format!for!3"4!hrs.!per!day,!6"7!days!per!week.!

Cyclical!breaths!strengthen!parasympathetic!(vagal)!tone.!!Increases!focus,!lowers!depression!and!possibly!anxiety!and!PTSD!symptoms.!

II"2! 30"60!mins.!for!some!effects,!30!mins.!daily!for!60!days!is!recommended.!

Completion!of!SKY!1!&!2!(2"3!full!days!each).!Supervised!SKY!trainings.!!

SKY!is!best!suited!for!in"CONUS!operations.!It!has!not!been!tested!in!theater.!

DiaphragmaticBreathing!

Group,!individual!or!multi"media!format!for!20!mins.!daily.!

Reverse!shallow!chest!breathing!associated!with!anxiety!and!hyper"arousal.!Thought!to!induce!greater!feelings!of!calm!and!relaxation.!

II"1! Unknown.! No!certification!required.!

Anywhere.!

TRM! Small!group!format,!3!full!days;!modified!TRM!being!piloted!for!individual!and!group!therapy.!!

Restore!ANS!balance!by!detecting!and!reversing!physiological!responses!to!trauma!reminders.!Thought!to!reduce!reactivity!to!trauma!reminders.!

II"1! 7"14!days!for!some!effects,!15!mins.!of!daily!practice!while!anxious!is!recommended.!!

Successful!completion!of!TRM!1!&!2.!Four!supervised!TRM!trainings.!!

TRM!is!practiced!in!CONUS,!O"CONUS!and!in!theater.!

TRE! 2!hour!workshop,!can!also!be!learn!through!self"instruction!50!minute!DVD!or!book.!!

Discharging!trapped!stress!by!inducing!tremors!in!muscle!groups.!Lowers!PTSD!symptoms.!

III! Effects!are!reportedly!immediate.!

!Certification!processes!available!through!TRE!organization!

Anywhere.!

Yoga!(asana)!postures!

Small!group!format,!1"2!hour!sessions.!

Discharges!trapped!stress!and!reverses!stress!postures!that!maintain!anxiety!and!stress.!!

I! Some!immediate!relief!reported.!No!dosage!studies.!

Months!to!years!depending!on!the!trainer!and!type!of!yoga!taught.!

Anywhere.!

MMFT! Small!group!format,!2!hrs.!daily!for!8!wks.!Given!pre"deployment.!!

Attention!control,!increased!cognitive!flexibility!and!executive!control.!Can!enhance!working!memory!function.!

II"1! 30!mins.!of!daily!practice!for!8!weeks!is!recommended.!!

Certification!not!yet!offered.!

Learned!in"!CONUS.!!Can!be!practiced!anywhere.!

MBSR! Small!group!format,!2"3!hrs.!daily!for!8!weeks.!

Attention!control,!increased!cognitive!flexibility!and!executive!control.!Lowers!stress!and!anxiety.!Increases!positive!emotions.!!

I! 45!mins.!of!daily!practice!is!recommended.!

Variable!depending!on!trainer.!Supervision!required.!

Best!learned!in"!CONUS,!once!mastered,!it!can!be!practiced!anywhere.!

Yoga!Nidra!(iRest),!

Small!group!format,!10"day!inpatient!training,!90!mins.!per!day!for!3!weeks.!Day!patients!listen!to!CD!for!30"60!mins/day.!!

Postulated!to!activate!the!PNS!through!conscious!use!of!techniques!that!are!meditative!and!visualization"based.!Claims!to!lower!anxiety,!anger!and!depression!and!increase!energy.!!

II"1! 30"60!mins.!of!daily!practiced!is!recommended.!Can!be!done!with!guided!CD!set.!

Trainers!can!be!certified!to!teach!iREST!after!Level!3!training!in!these!therapeutic!facilities.!

iRest!is!best!practiced!in!CONUS!settings.!Once!mastered,!it!can!be!practiced!anywhere.!

CMBM! Small!group!format,!5!day!training.!Training!given!after!exposure!to!trauma.!!

Course!teaches!self"care!psychoeducation!and!coping!skills!as!well!as!meditation,!guided!imagery!and!biofeedback!(using!bio"dots),!physical!exercise,!dance,!yoga,!and!Tai!chi.!Goal!is!reduction!in!PTSD!and!trauma!symptoms.!!

II"1! No!predetermined!practice!recommendations.!

Trainers!can!be!certified!after!passing!the!basic!and!Advanced!(5"day!training)!course.!!

CMBM!can!be!practiced!in!CONUS,!O"CONUS!or!in!theater.!Course!is!currently!offered!stateside!and!in!disaster!trauma!settings.!!!

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Benson"Henry!Institute!at!MGH:!RR/Resiliency!Program!

Small!group!format,!2!hr.!weekly!sessions!for!8!weeks!(16!hrs.!total).!!

Training!in!Relaxation!Response!(RR);!cognitive!skills;!positive!psychology!(belief,!optimism!and!meaning);!spiritual!connectedness;!and!exercise!and!nutrition!in!a!setting!with!social!support.!Enhances!resiliency!while!reducing!stress/allostatic!load!thus!improving!health!and!performance.!

I 10"30!mins. twice!daily!RR!practice!for!8!weeks!and!then!daily!thereafter.!Booster!session!with!trainer!at!3"6!month!intervals!is!recommended.!!!

Manualized!training!with!certificate!of!completion;!Certification!not!yet!offered.!

Training!sessions!in!CONUS!settings.!Once!learned!and!personally!integrated!into!daily!routine,!it!may!be!practiced!anywhere.!

Guided!Imagery!

Group,!individual!or!self"administered!audio!format.!!25–!90!mins.!daily.!

Enhances!performance,!decreases!stress,!pain,!anxiety,!PTSD!and!depression.!Visualization!activates!brain!and!ANS.!!

I! 30!mins.!of!daily!practice!for!8!weeks.!

N/A.! Anywhere.!

!Although!a!number!of!promising!integrative!practices!were!identified,!the!results!of!the!present!literature!review!also!suggest!that!practices!designed!to!enhance!autonomic!regulation!are!infrequent!topics!of!scientific!study,!especially!in!military!populations.!In!the!past!3!decades,!experimental!human!studies!began!to!identify!biological!substrates!that!mediate!cognitive!control!mechanisms!and!autonomic!mechanisms!for!stress!regulation!and!executive!functions.!Nevertheless,!the!biological!basis!of!cognitive"emotional!resilience!is!poorly!understood,!and!there!are!few!well"designed!randomized!controlled!studies!examining!integrative!mind"body!practices!that!may!prove!promising!for!enhancing!autonomic!control.!!Research!into!integrative!practices!for!regulating!emotion!and!arousal!is!further!confounded!by!the!use!of!practices!containing!multiple!potentially!effective!ingredients.!More!specifically,!breathing!practices!often!combine!several!breathing!techniques!(e.g.,!SKY!practice!combines!slow,!medium!and!fast"paced!breathing!and!slow"paced!breathing!often!incorporates!diaphragmatic!breathing!practices).!More!studies!are!needed!to!isolate!potentially!effective!breathing!components!so!that!their!relative!effectiveness!can!be!evaluated.!In!the!area!of!manipulative!body"based!practices!(e.g.,!yoga!or!TRM),!popular!techniques!often!contain!a!breathing!or!meditation!component!to!the!practice.!As!with!breathing!techniques,!these!elements!need!to!be!isolated!to!determine!if!manipulative!body"based!techniques!alone!can!produce!beneficial!results.!Finally,!most!mindfulness!as!well!as!meditation!and!guided!imagery!techniques!are!partnered!with!other!practices!(e.g.,!yoga!or!relaxation!techniques)!as!part!of!the!training!practice!and!these!elements!need!to!be!isolated!to!determine!if!mindfulness!alone!is!effective.!!The!all"too"frequent!bundling!of!techniques!makes!it!difficult!to!definitively!ascertain!which!core!biological!mechanisms!of!action!might!be!at!work,!as!well!as!which!facets!of!practice!account!for!program!success.!While!combinations!of!techniques!may!work!together!to!produce!beneficial!results!in!some,!if!not!most,!cases,!the!relative!contribution!of!elements!working!to!produce!benefits!is!also!an!area!meriting!further!investigation.!!

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Finally,!confusing!and!sometimes!contradictory!terminology!within!the!field!of!integrative!health!and!wellness!makes!unified!or!standardized!research!difficult.!There!is!no!standard!definition!for!the!concept!of!“integrative”!or!“mind"body!skills”!in!human!studies,!nor!is!there!a!standard!definition!of!“mindfulness,”!“yoga”!or!“breath”!techniques.!!Lack!of!consensus!around!basic!terms!would!appear!not!only!to!further!impede!data!interpretation!across!the!current!literature!but!also!to!hinder!data!sharing!across!disciplines.!!!This!paper!concludes!that,!though!evidence!is!limited!across!breathing!practices,!manipulative!body"based!techniques!and!mindfulness!practices,!a!number!of!integrative!practices!may!prove!promising!for!regulating!the!autonomic!nervous!system.!While!some!of!these!practices!have!been!tested!in!civilian!settings,!their!adaptation!into!real"world!military!settings!remains!largely!untested.!Relatively!stronger!evidence!exists!for!mindfulness,!guided!imagery,!yoga,!and!integrated!mind"body!programs.!!In!terms!of!other!tension"modulation!techniques,!research!findings!related!to!TRM!appear!promising!and!although!TRE!has!no!systematic!research,!it!remains!intriguing!because!of!it’s!simplicity,!brevity,!and!immediate!effects,!though!research!is!needed!to!determine!the!mechanism!of!the!neurotremor!release!response!and!potential!clinical!applications.!!It!should!also!be!noted!that!various!forms!of!controlled!breathing,!meditation,!guided!imagery!and!biofeedback!are!already!being!employed!by!clinicians!providing!services!within!military!settings.!Although!some!of!these!techniques!are!being!used!in!pre,!post!and!during!combat!settings,!to!the!best!of!our!knowledge!at!the!time!that!this!report!was!completed,!none!of!the!techniques!reviewed!have!been!tested!or!compared!across!different!military!settings,!pre"deployment,!while!deployed/during!combat,!and!after!deployment.!Such!research!is!likely!to!hold!potential!for!identifying!recommended!uses!and!limits!of!use!for!integrative!practices.!!!

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Appendix!A:!Glossary!of!Terms!!Autonomic!Nervous!System!(ANS)!

Part of the peripheral nervous system that acts as a control system, maintaining homeostasis in the body. These maintenance activities are primarily performed without conscious control or sensation. The ANS has far reaching effects, including: heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils, micturition - (the discharge of urine), and erection. Whereas most of its actions are involuntary, some ANS functions work in tandem with the conscious mind, such as breathing. Its main components are its sensory system, motor system (comprised of the parasympathetic nervous system and sympathetic nervous system), and the enteric nervous system .!

Sympathetic!Nervous!System!(SNS)!

A branch of the autonomic nervous system. It is always active at a basal level (called sympathetic tone) and becomes more active during times of stress or anxiety. Its actions during the stress response comprise the fight-or-flight response .!

Parasympathetic!Nervous!System!(PNS)!

A branch of the autonomic nervous system. It is always active at a basal level (called parasympathetic tone) and becomes more active during times of relaxation. It can be seen in lowered heart rate and breathing, in warm, flushed skin, and lowered blood pressure.!

Basal!heart!rate! An indicator of Autonomic Nervous System Activity. The number of times heart beats per minute while at complete rest. Higher heart rates indicate greater stress and anxiety and lower heart rates indicate feelings of calm and relaxation. !

Heart!Rate!Variability!!

A measure of Autonomic Nervous System Activity. HRV reflects the healthy alternating balance of sympathetic and parasympathetic effects, and increased HRV is associated with improved cognitive performance. Low rate variability signals an imbalance of these influences, with sympathetic tone generally predominating.

Vagal!Fibers!(tone)!!

The vagal and sympathetic nervous system constantly interacts. The stimulation of the vagal afferent fibers leads to inhibition of sympathetic efferent activity. The opposite reflex events are mediated by stimulation of sympathetic afferent activity. Increased vagal tone is typically associated with greater feelings of relaxation and calm.

Pre"Frontal!Cortex! Part of the cerebral cortex that is the center of judgment/ decision-making, and planning.!Cortical! Of or relating to the cerebral cortex, the outer portion of the cerebrum and the main part of the brain. It

plays a key role in memory, attention, perceptual awareness, thought, language and consciousness .!Sub"Cortical!!

Relating to, involving, or being nerve centers below the cerebral cortex. Primarily non-conscious activities of a sensory and motor nature.

Limbic!System!!

A system of functionally related neural structures in the brain that are involved in emotional behavior.!

Respiratory!Alkatosis!!

Respiratory alkalosis is a medical condition in which increased respiration (hyperventilation) elevates the blood pH (a condition generally called alkalosis). Alkalosis is caused by excessive elimination of carbon dioxide due to a respiratory abnormality, such as hyperventilation.

Integrative!practice!

An integrative practice implies a practice that offers multiple and diverse therapies—both conventional and complementary. The use of the word integrative grants specific allowance to a centralized mode of delivery. Thus, one practitioner with training in both conventional and complementary practices and principles is an integrative practitioner. His or her practice then becomes an integrative practice.

!Eastern!medicine! A term that encompasses a whole system of medical practices performed in different countries in Asia, which include acupuncture, martial arts, herbal medicine, Feng Shui and massage (e.g., shiatsu). Of these therapies, acupuncture and Chinese herbology are the most popular in the United States. Some additional therapies include diet, nutrition and lifestyle counseling as well as Tai chi and qigong (physical exercise) and tui’na (manual therapies). Because many of the Asian medicines and therapies are rooted in the Chinese philosophy and the principles of Chinese medicine, the monograph focuses mainly on Chinese medicine.!

Cortisol! A vital hormone commonly known as the 'stress hormone,' as it is involved in our response to stress.Cortisol is typically high during periods of stress and low when relaxing.

Yoga! Used for health purposes, it typically combines physical postures, breathing techniques and meditation or relaxation. People use yoga as part of a general health regimen and also for a variety of health conditions.

Mindfulness! A conscious mental process using certain techniques—such as focusing attention or maintaining a specific posture—to suspend the stream of thoughts and relax the body and mind. It is used to increase

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calmness and relaxation, improve psychological balance, cope with illness, or enhance overall health and well-being. Techniques include specific postures, focused attention or an open attitude toward distractions.!

Tai!chi! A Chinese martial art that often involves the practice of a flowing movement in slow motion (moving meditation).

Western!medicine! A system in which medical doctors and other health care professionals (such as nurses, pharmacists and therapists) treat symptoms and diseases using drugs, radiation or surgery. Also called allopathic medicine, biomedicine, conventional medicine, mainstream medicine and orthodox medicine.

Mainstream!medicine!

The science and art (ars medicina) of healing. It encompasses a range of health care practices evolved to maintain and restore health by the prevention and treatment of illness.!

Post"traumatic!stress!disorder!

A severe anxiety disorder that can develop after exposure to a traumatic event that involved loss or threatened loss of life.

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Appendix!B:!Additional!Resources!

Breath Techniques for ANS Regulation Paced-Breath http://perfectbreathing.com/pace-breathing SKY/Warrior Breath http://www.artoflivingyoga.org/sudarshan-

kriya.html iBreathe/Breathe2Relax™ www.t2health.org/

Manipulative Body-Based and Tension-Release Techniques for ANS Regulation Yoga http://www.yogaweb.com/yoga/essentials/history

http://www.yogajournal.com/ Trauma Resiliency Model http://www.traumaresourceinstitute.com/ Tension and Trauma Releasing Exercises http://traumaprevention.com/

Mindfulness And Guided Imagery Mindfulness-Based Stress Reduction (MBSR)! http://www.mind-fitness-training.org/ Mindfulness Mind-Fitness Training (MMFT) http://mind-fitness-training.org/tr_what.html Yoga Nidra Meditation! http://www.irest.us/Health Journeys Guided Imagery http://healthjourneys.com

Mind Body Programs The Center for Mind Body Medicine http://www.cmbm.org/ Benson-Henry Institute for Mind Body Medicine!

http://www.mgh.harvard.edu/bhi/about/!

Organizations/Research Centers Agency for Healthcare Research and Quality http://www.ahrq.gov Alternative Medicine Foundation http://www.amfoundation.org/index.htm Benson-Henry Institute for Mind Body Medicine!

http://www.mgh.harvard.edu/bhi/about/!

British Society of Integrated Medicine http://www.bsim.org.uk Consortium of Academic Health Centers for Integrative Medicine

http://www.imconsortium.org

International Society for Complementary Medicine Research (ISCMR)

http://www.iscmr.org

National Committee for Quality Assurance (NCQA)

http://www.ncqa.org

National Institutes of Health: National Center for Complementary and Alternative Medicine

http://nccam.nih.gov

Samueli Institute http://siib.org

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The Center for Integrative Medicine at the George Washington University Medical Center

http://integrativemedicinedc.com

U. Mass Medical School Center for Mindfulness

http://www.umassmed.edu/cfm/home/index.aspx

University of Maryland School of Medicine: The Center for Integrative Medicine (CIM)

http://www.compmed.umm.edu

Wholistic Healing Research http://www.wholistichealingresearch.com !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

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Appendix!C:!Interviewee!List!!

Name! Organization! Title!

Richard!Davidson,!PhD!!Waisman!Center!for!Brain!Imaging!and!Behavior!

Director,!Waisman!Center!for!Brain!Imaging!and!Behavior!

University!of!Wisconsin,!Madison!

Jon!Kabat"Zinn,!PhD! Mindfulness!in!Medicine,!Health!Care,!and!Society!

Director,!Mindfulness!in!Medicine,!Health!Care,!and!Society:!University!of!Massachusetts!Medical!School!

John!Killen,!PhD!National!Center!for!Complementary!and!Alternative!Medicine!(NCAMM)!

Deputy!Director,!National!Center!for!Complementary!and!Alternative!Medicine!(NCAMM)!

James!Gordon,!MD! The!Center!for!Mind"Body!Medicine!Founder/Director,!The!Center!for!Mind"Body!Medicine!

Gregory!L.!Fricchione,!MD!! Benson"Henry!Institute!for!Mind!Body!Medicine!

Director,!Benson"Henry!Institute!for!Mind!Body!Medicine!!

Elaine!Miller"Karas,!LCSW! The!Trauma!Resource!Institute!Co"Director!and!Co"Founder,!The!Trauma!Resource!Institute!

Laurie!Leitch,!PhD! The!Trauma!Resource!Institute!Co"Director!and!Co"Founder,!The!Trauma!Resource!Institute!

Jennifer!Alford,!PhD!National!Center!for!Telehealth!and!Technology!

Director,!National!Center!for!Telehealth!and!Technology!

Matt!Fritts,!MPH! The!Samueli!Institute!Senior!Research!Associate!at!Samueli!Institute!

Elizabeth!Stanley,!PhD! Mindfulness!Based!Mind"Fitness!Training!Founder/Director,!Mindfulness!Based!Mind"Fitness!Training!Georgetown!University!

Emma!Seppala,!PhD!Waisman!Center!for!Brain!Imaging!and!Behavior!

!Research!Associate,!University!of!Wisconsin"Madison!

Belleruth!Naparstek!Heath!Journeys:!The!Guided!Imagery!Resource!Center!

Founder/Director,!!Health!Journeys!!

David!Berceli,!PhD!TRE:!Tension!and!Trauma!Release!Exercises!!

Founder,!Director!,!TRE!

Jennifer!L!Strauss,!PhD!Center!for!Excellence!in!Health!Services!Research!

Assistant!Professor,!Center!for!Excellence!in!Health!Services!Research;!Duke!University!

Charles!Hoge,!M.D.,!COL(ret)!Walter!Reed!Army!Institute!of!Research,!Walter!Reed!Army!Medical!Center,!Army!Surgeon!General’s!Office!

Senior!Scientist!

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se!of!b

iofeed

back!as!

well!as!to!gauge!whe

ther!stress!and!anxiety!levels!are!excessive!or!sub"optim

Measuremen

Particular!device!used!

to!obtain!measuremen

t!Exam

ples!of!T

URL!Link!

Measuremen

t!Metho

Descriptio

n!of!to

ysiologic!

Process!Exam

:!!Nervous!System!

controlled!target!

organ!activ

Usability:!!

Durability/!User"friend

liness*!

ples!of!U

tilization!

Ideal!app

lication!of!to

Eviden

ce"Based!Sup

Research!sup

porting!tool!

reliability!and!validity

! SenseW

ia,!201

http://sen

sewear.bo

dia.com/!

Worn!arou

e!arm!to!

itor!m

otion,!physical!

ity!levels,!skin!

rature,!heat!flux,!

galvanic!skin!respon

•!Galvanic!Skin!

Respon

•!Heart!ra

te!variability!

•!Skin!Tem

perature!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

•!Week!following!stressor

•!Health!Baseline!

3! ! !

band!Pulse"m

Polar!W

earlink!+!

Transm

itter!

(Nike!Inc,!2010)!

http://store.nike.com/us/e

n_us/?sitesrc=uslp&l=shop

,search,searchList"

heart%

2520rate%2520mo

nitor#l=shop

inline/cid"1/pid"35

Strapp

ed!aroun

d!the!arm!to!

measure!heart!ra

te!with!

verbal!and!visual!feedb

•!Heart!ra

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

N!®!7!Series™!

Wrist!(7!Serie

s!Wrist,!

http://w

ww.omronh

care.com/produ

cts/7"

s"wrist/!

Device!worn!on!th

e!wrist!to!

detect!blood!pressure,!

heart!rate!and!arrhythm

•!Bloo

d!pressure!

•!Heart!Rate!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

Sphygm

ometer!

N!®!10!Serie

s!™!(1

0!Serie

s,!2010)!

http://w

ww.omronh

care.com/produ

cts/10"

Portable!blood!pressure!

cuff!and!m

r!measure!

d!pressure!

•!Bloo

d!pressure!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

Intelligent!Garmen

! Biod

evices!®!Vita

l!Jacket!(B

vices!

Vital!Jacket,!20

http://w

ww.biode

vices.pt/!

!EKG!is!m

red!by!

wearin

g!a!light!t"shirt!and!

placing!a!sm

all!device!in!th

e!user’s!pocket.!Data!can!be!

collected!on!a!storage!

device!or!sen

t!real"tim

e!to!a!

•!Electrocardiograph

y!•!Heart!Rate!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

Peak!Flow!M

! Assess!®!Peak!Flow!

http://assesspeakflow.re

nics.com

Respira

tory,!inspiratory!and!

•!Maxim

um!spe

ed!of!

expiratio

agnitude!

•!Po

rtable

•!No!skilled!te

chnician!

•!Biofeedb

•!Im

iately!fo

llowing!

!! !! !

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!M

lls fo

! !54!

Measuremen

t!Exam

ples!of!T

URL!Link!

Measuremen

t!Metho

Descriptio

n!of!to

ysiologic!

Process!Exam

:!!Nervous!System!

controlled!target!

organ!activ

Usability:!!

liness*!

ples!of!U

tilization!

Ideal!app

lication!of!to

Eviden

ce"Based!Sup

Research!sup

porting!tool!

Meter!(A

ssess!Pe

Flow!M

eter,!201

expiratory!volum

es!are!

measured!by!breathing!in!

and!ou

t!of!m

outh!valve.!

Available!in!m

anual!flow!

meters!on

of!airw

ay!obstructio

n!in!lungs)!

•!Durable!

•!User"friend

ly!ope

stressor!

! Mini"W

right!®!Peak!

Flow!M

(Mini!W

right!Peak!

Flow!M

eter,!201

http://m

iniwrig

wmeter.com

tory!inspira

tory!and!

expiratory!volum

es!are!

measured!by!breathing!in!

and!ou

t!of!m

outh!valve.!

Available!in!m

anual!or!

digital!flow!m

eters!

•!Maxim

um!spe

ed!of!

expiratio

agnitude!

of!airw

ay!obstructio

n!in!lungs)!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

Carepe

utic!ECG!

Heart!Health!M

r!(Active!Forever,!

http://w

ww.activeforever.

com/p"248

07"carep

eutic"

ecg"fda"approved"heart"

health"

itor.a

spx?cm

_mmc=fr

oogle"_"na"_"na"_"

nacarepe

utic"ecg"fda"

approved"heart"health"

itors!and!analyzes!the!

heart’s!con

arrhythm

ias!and!he

art!rate.!!

Display!screen!show

waveform!and!heart!ra

•!Electrocardiograph

•!Heart!ra

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

Person

al!Digita

l!Assistant!(P

itorin

g!System!

StressEraser®!

(StressEraser®,!201

http://stresseraser.c

al!hand"he

biofeedb

ack!de

vice!th

uses!a!finger!sen

sor!to!

convert!p

ulse!into!heart!

rate!variability!wave!

•!Heart!ra

te!variability!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

emWave!Pe

Stress!Reliever®!

(Institu

te!of!

HeartMath,!200

http://store.heartmath.or

g/store/em

held/emwave"

held"silver!

Hand"he

ld!device!that!

measures!he

art!rate!

bility!to!determine!

effects!of!differen

t!levels!of!

stress!

•!Heart!ra

te!variability!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

cket!Heart!Rate!

meter!

(Markw

ort,!20

http://w

ort.co

odel_view.asp?m

Measures!he

art!rate!

(beats!per!m

inute),!

ts!steps,!m

iles!and!

calorie

s,!and!has!an!

exercise!timer!

•!!Heart!ra

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

!•!Biofeedb

•!Im

iately!

following!stressor!

!! !! !

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!M

lls fo

! !55!

Measuremen

t!Exam

ples!of!T

URL!Link!

Measuremen

t!Metho

Descriptio

n!of!to

ysiologic!

Process!Exam

:!!Nervous!System!

controlled!target!

organ!activ

Usability:!!

liness*!

ples!of!U

tilization!

Ideal!app

lication!of!to

Eviden

ce"Based!Sup

Research!sup

porting!tool!

Meta!1075!Heart!

Rate!M

r!(Spo

rt!Line,!200

http://w

ww.spo

rtline.com

/produ

ct.php

?prod=

ECG!accurate!continuo

read!heart!ra

r,!audible!in"ear!zon

e!training!

indicator!

•!!Heart!ra

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

Colvard!Pu

pillometer!

edical,!

http://w

ww.oasismed

com/Produ

cts_Nod

e_View

.asp?id=

Portable!device!that!uses!

light!amplificatio

measure!pup

il!size!in!

darken

ed!space!

•!Pu

pillary!dilatio

•!Po

rtable!

•!Skilled!te

chnician!re

d!•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

rOptics!VIP™"200!

Pupillometer!

roptics!Inc,!

http://w

ww.neu

roptics.co

An!electronic,!infrared!

device!th

easures!the!

reactiv

ity!of!the!pup

il!to!

light.!!Used!in!prelim

inary!

inations!of!p

atients!

who!have!sustaine

significant!head!injury!

•!Pu

pillary!dilatio

•!Po

rtable!

•!Skilled!te

chnician!re

d!•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

Pupillo

meter!

ic!Binocular!

Infrared!Pup

(Rosen

,!Gore,!Taylor,!

ara,!&!How

http://w

ww.procyon

.co.uk

/dynam

ic.php!

Uses!dynamic!pup

easure!pup

il!motion!in!

respon

se!to!brie

f!flashes.!

Device!includ

es!small!laptop!

ired!to!m

r!results!

•!Pu

pillary!dilatio

•!Po

rtable!

•!Skilled!te

chnician!re

d!•!Durable!

•!User"friend

ly!ope

•!Biofeedb

•!Im

iately!fo

llowing!

stressor!

ADTEMP!I!#41

ERMOMETER!

(ADTEMP!I!#41

2!Thermom

eter,!201

http://w

ww.digita

lthermo

meters.ne

t/adtempiand1

12thermom

eter.aspx!

!Detects!bod

y!tempe

rature!

orally,!rectally!and!und

the!arm!

•!Tempe

rature!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

!Health!Baseline!

Thermom

eter!(O

Vicks!Digita

l!Thermom

eter!30!

Second!Reading!

(Vicks!Digita

l!Thermom

eter,!201

http://w

ww.walgreens.co

m/store/c/vicks"digita

l"thermom

eter/ID=p

986"prod

Detects!bod

y!tempe

rature!

orally,!rectally!and!und

the!arm!

•!Tempe

rature!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

Health!Baseline!

! !56!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!M

lls fo

!! !! !

Measuremen

t!Exam

ples!of!T

URL!Link!

Measuremen

t!Metho

Descriptio

n!of!to

ysiologic!

Process!Exam

:!!Nervous!System!

controlled!target!

organ!activ

Usability:!!

liness*!

ples!of!U

tilization!

Ideal!app

lication!of!to

Eviden

ce"Based!Sup

Research!sup

porting!tool!

BestMed!Digita

l!Temple!

Thermom

eter!Instant!

Read!Non"In

vasive!

(Digita

Thermom

eter!Instant!

Read!Non"In

vasive"

BestMed!Health!&!

Wellness!Med

icine!

Cabine

http://w

ww.kmart.c

c/s/p_

104_03

01P?vN

=Health

Wellness

ame=Med

icineC

abinet

ame=Th

eters&

KDx200

70926x0000

3a&ci_src=14110944&

ci_sku

Detects!skin!tempe

rature!

by!sen

sing!heat!a

t!the!

temple!

•!Tempe

rature!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

!Health!Baseline!

Braun"Thermoscan!

ometer!

(Braun"The

rmoscan!

ometer,!

http://w

ww.walmart.com

/ip/Braun"The

rmoscan"Ear"

Thermom

eter/986

Detects!bod

y!tempe

rature!

through!measurin

g!infrared!

heat!in!th

e!ear!canal!

•!Tempe

rature!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

!Health!Baseline!

2!Skin!The

Walgreens!FHT5!

Digita

Thermom

eter!8!

Second!(W

algreens!

FHT5!Digita

Thermom

eter!8!

Second

http://w

ww.walgreens.co

m/store/catalog/Sup

plies/

FHT5"Digita

Thermom

eter/ID=p

uct?V=

G&ec=frgl_&ci

_src=141

4&ci_sku=sk

u60002

Detects!skin!tempe

rature!

by!sen

sing!heat!a

t!the!

temple!

•!Tempe

rature!

•!Po

rtable!

•!No!skilled!te

chnician!

•!Durable!

•!User"friend

ly!ope

!Health!Baseline!

User"friend

ly!ope

n!includ

es!painless,!non"in

vasive,!non"stig

matizing!op

eration!!!

**!Based!on!the!following!scale:!

!0!(No!eviden

!1!(One!to!th

ree!articles!supp

ort!the!to

ol’s!re

liability)!

!2!(Fou

r!to!10!articles!supp

ort!the!to

ol’s!re

liability)!

ore!than!10!articles!supp

ort!the!to

ol’s!re

liability)!

! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Mind Body Skills for Regulating the Autonomic Nervous System

CITED!SOURCES!FOR!APPENDIX!D!

1. BodyMedia.!Sense!Wear.!Available!at:!http://sensewear.bodymedia.com/SW"Learn"More/How"SenseWear"Works.!Accessed!Jan!24,!2011.!

2. Nike!Inc.!Polar!Wearlink!+!Transmitter.!Available!at:!http://store.nike.com/us/en_us/?sitesrc=uslp&l=shop,search,searchList"heart%2520rate%2520monitor#l=shop,pdp,ctr"inline/cid"1/pid"351634.!Accessed!January!24,!2011.!

3. 7!Series!Wrist.!Omron!Healthcare!Inc.!Available!at:!http://www.omronhealthcare.com/products/7"series"wrist/.!Accessed!Jan!24,!2011.!

4. 10!Series.!Omron!Healthcare!Inc.!Available!at:!http://www.omronhealthcare.com/products/10"series/.!Accessed!Jan!24,!2011.!

5. Biodevices!Vital!Jacket.!Biodevices.!Available!at:!http://www.biodevices.pt/.!Accessed!Jan!24,!2011.!6. Assess!Peak!Flow!Meter.!Philips.!Available!at:!http://assesspeakflow.respironics.com/.!Accessed!Jan!24,!

2011.!7. Mini!Wright!Peak!Flow!Meter.!Mini!Wright!Peak!Flow!Meter.!Available!at:!

http://miniwrightpeakflowmeter.com/.!Accessed!Jan!24,!2011.!8. Active!Forever.!Carepeutic!ECG!FDA!Approved!Heart!Health!Monitor.!Available!at:!

http://www.activeforever.com/p"24807"carepeutic"ecg"fda"approved"heart"health"monitor.aspx?cm_mmc=froogle"_"na"_"na"_"nacarepeutic"ecg"fda"approved"heart"health"monitor.!Accessed!January!24,!2011.!

9. StressEraser®.!StressEraser!Personal!Feedback!Device.!Available!at:!http://stresseraser.com/.!Accessed!February!02,!2011.!

10. Institute!of!HeartMath.!emWave!Personal!Stress!Reliever.!Available!at:!http://store.heartmath.org/store/emwave"handheld/emwave"handheld"silver.!Accessed!February!02,!2011.!

11. Markwort.!Markwork!Pulse!Pedometer.!Available!at:!http://www.markwort.com/model_view.asp?model=9258.!Accessed!Jan!24,!2011.!

12. Sport!Line.!Available!at:!http://www.sportline.com/product.php?prod=70.!Accessed!Jan!24,!2011.!13. OASIS!Medical.!Colvard!Pupillometer.!Available!at:!

http://www.oasismedical.com/Products_Node_View.asp?id=58.!Accessed!February!02,!2011.!14. Neuroptics!Inc.!Opthalmology.!Available!at:!http://www.neuroptics.com/.!Accessed!February!02,!2011.!15. Rosen!ES,!Gore!CL,!Taylor!D,!Chitkara!D,!Howes!F.!Use!of!a!digital!infrared!pupillometer!to!assess!patient!

suitability!for!refractive!surgery.!Journal!of!Cataract!and!Refractive!Surgery.!August!2002;8:1433"1438.!16. ADTEMP!I!#412!Thermometer.!Digital!Thermometers.!Available!at:!

http://www.digitalthermometers.net/adtempiand153412thermometer.aspx.!Accessed!Jan!24,!2011.!17. Vicks!Digital!Thermometer.!Walgreens.!Available!at:!http://www.walgreens.com/store/c/vicks"digital"

thermometer/ID=prod4986"product.!Accessed!Jan!24,!2011.!18. Digital!Temple!Thermometer!Instant!Read!Non"Invasive"BestMed!Health!&!Wellness!Medicine!Cabinet.!

Kmart.!Available!at:!http://www.kmart.com/shc/s/p_10151_10104_038W595304110001P?vName=Health%20&%20Wellness&cName=MedicineCabinet&sName=Thermometers&sid=KDx20070926x00003a&ci_src=14110944&ci_sku=038W595304110001P.!Accessed!Feb!02,!2011.!

19. Braun"Thermoscan!Ear!Thermometer.!Walmart.!Available!at:!http://www.walmart.com/ip/Braun"Thermoscan"Ear"Thermometer/9863501.!Accessed!Feb!02,!2011.!

20. Walgreens!FHT5!Digital!Temple!Thermometer!8!Second.!Walgreens.!Available!at:!http://www.walgreens.com/store/catalog/Supplies/FHT5"Digital"Temple"Thermometer/ID=prod6000661"product?V=G&ec=frgl_&ci_src=14110944&ci_sku=sku6000299.!Accessed!Feb!02,!2011.!

!! ! 57!

integrative mind body skills for regulating the autonomic ... · 2345 crystal drive! crystal park...

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